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BULLETIN  30 

Of  THE  COMMITTEE  OF  ONE  HUNDRED 
ON  NATIONAL  HEALTH 


REPORT  ON  NATIONAL  VITALITY 

ITS  WASTES  AND  CONSERVATION 


PREPARED  FOR  THE  NATIONAL  CONSERVATION  COMMISSION 

By  PROFESSOR  IRVING  FISHER 


OP  YALE  UNIVERSITY,  MEMBER 
OF  THE  COMMISSION 


WASHINGTON 

GOVERNMENT  PRINTING   OFFICE 

1909 


Digitized  by  tine  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/reportonnationalOOfish 


001^TEJN"TS. 


BY  PARTS. 

Chapters. 

Part  I.  The  length  of  life  versus  mortality I-II 

II.  The  breadth  of  life  versus  invalidity III-V 

III.  Methods  of  conserving  life VI-X 

IV.  Results  of  conserving  life XI-XI V 


BY  CHAPTERS. 

Part  I. 

Page. 

Chapter      I.  The  length  of  life 16 

II.  The  mortality  rate 19 

Part  II. 

Chapter  III.  Prevalence  of  serious  illness 33 

IV.  Prevalence  of  minor  ailments 38 

V.  Prevalence  of  undue  fatigue 40 

Part  III. 

Chapter  VI.  Conservation  through  heredity 49 

VII.  Conservation  through  public  hygiene 55 

VIII.  Conservation  through  semipublic  hygiene 64 

IX.  Conservation  through  personal  hygiene 82 

X.  Are  hygienic  measures  eugenic? 97 

Part  IV. 

Chapter  XI.  Prolongation  of  life 102 

XII.  The  money  value  of  increased  vitality 117 

XIII.  The  general  value  of  increased  vitality 124 

XIV.  Things  which  need  to  be  done 126 

III 


IV 


CONTENTS. 
BY  SECTIONS. 


Acknowledgments vii 

Suggestions  for  readers ix 

Abstract 1 

Summaries  by  chapters  and  sections 2 

Introduction 14 


Chapter  I. 
The  length  of  life. 


Section  1.  In  different  places  . 
2.  At  different  times  . 


16 
17 


Chapter  II. 
The  mortality  rate. 

Section  1.  Relation  of  longevity  and  mortality 19 

2.  Mortality  in  various  regions 20 

3.  Urban  and  rural  mortality 21 

4.  Eace  and  condition 22 

5.  Mortality  historically 24 

6.  Adult  and  infant  mortality 25 

7.  Particular  diseases 27 


Chapter  III. 
Prevalence  of  serious  illness. 


Section  1.  Loss  of  time 

2.  Particular  diseases. 


33 
34 


Chapter  IV. 
Prevalence  of  minor  ailments. 


Section  1.  Importance  of  minor  ailments 

2.  Preventability  of  minor  ailments 


38 
40 


Chapter  V. 
Prevalence  of  undue  fatigue. 

Section  1.  Strength,  endurance,  and  fatigue 40 

2.  Alcohol  and  fatigue 41 

3.  Tobacco  and  fatigue 42 

4.  Diet  and  fatigue 42 

5.  Exertion  and  fatigue 44 

6.  The  working  day 45 

7.  Importance  of  preventing  undue  fatigue 47 


Chapter  VI. 
Conservation  through  heredity. 

Section  1.  Heredity  and  environment 49 

2.  Eugenics _ .         50 

3.  Eugenics  and  law 51 


CONTENTS.  V 

Chapter  VII. 

Conservation  through  public  liyr/iene. 

Page. 

Section  1.  Municipal  hygiene 55 

2.  State  hygiene - - 59 

3.  Federal  hygiene 61 

Chapter  VIII. 
Conservation  througli  semipublic  hygiene. 

Section  1.  Medical  research  and  instruction 64 

2.  The  medical  profession 65 

3.  Institutional  hygiene ^ 70 

4.  School  hygiene - 72 

5.  Voluntary  and  business  organizations 79 

Chapter  IX. 

Conservation  through  personal  hygiene. 

Section  1.  Ita  importance 82 

2.  Branches  of  personal  hygiene 83 

3.  The  hygiene  of  environment 84 

4.  The  hygiene  of  nutrition 86 

5.  Drug  habits 88 

6.  Activity  hygiene 90 

7.  Sex  hygiene 92 

8.  Personal  hygiene  in  general 95 

Chapter  X. 

Are  hygienic  measures  eugenic  f 

Section  1.  Prolongation  of  weak  lives ■ 97 

2.  Children' s  diseases  impair  both  fit  and  unfit 99 

3.  Fitness  is  relative  to  environment 100 

Chapter  XI. 

Prolongation  of  life. 

Section  1.  Life  is  lengthening 102 

2.  Table  showing  further  practicable  prolongation 103 

3.  Diagram  showing  effect  of  prolongation  at  different  ages 107 

4.  Fifteen  years  a  safe  minimum  estimate  of  prolongation  possible 109 

5.  Need  of  lengthening  human  life Ill 

6.  The  normal  lifetime Ill 

Appendix  to  Chapter  XI. 

Method  of  computing  possible  prolongation  of  life. 

Section  1.  "Expectations"  at  median  ages  as  short  cut  to  average  expecta- 
tions    112 

2.  Basis  of  estimates  of  preventability 113 

3.  Meaning  of  "preventable" 114 

4.  Error  from  abnormal  age  distribution  of  deaths  in  1906 115 

5.  Ratios  of  preventability  by  ages  derived  from  ratios  by  diseases  . . .  116 

6.  Allowance  for  weakness  of  prolonged  lives 116 

7.  Diagram  "Possible  I"  making  this  allowance  compared  with  "Pos- 

sible II"  omitting  it 116 

8.  Reciprocal  relation  between  longevity  and  mortality  shown  by  dia- 

gram    117 


VI  CONTENTS. 

Chapter  XII. 

The  money  value  of  increased  vitality. 

Page. 

Section  1.  Money  appraisal  of  preventable  wastes 117 

2.  The  cost  of  conservation 121 

Chapter  XIII. 

The  general  value  of  increased  vitality. 

Section  1.  Disease,  poverty,  and  crime 124       | 

2.  Conservation  of  natural  resources 125       ' 

Chapter  XIV. 

Things  which  need  to  he  done. 

Section  1.  Enumeration  of  principal  measures 126 

Index 131 


NATIONAL  VITALITY,  ITS  WASTES  AND  CONSERVATION. 


By  Irving  Fisher, 
Professor  of  Political  Economy,  Yale  University. 


ACKNOWLEDGMENTS. 

The  materials  upon  which  this  report  is  principally  based  were 
collected  during  the  last  ten  years.  They  are  far  from  complete,  and 
I  had  expected  to  make  use  of  them  at  my  leisure  for  a  series  of 
special  articles,  but  the  opportunity  which  suddenly  presented  itself 
of  utilizing  them  in  the  construction  of  this  report  was  one  which 
could  not  be  resisted,  despite  the  fact  that  the  time  available  was 
only  three  months.  In  the  endeavor  to  make  the  best  use  of  this 
time  I  have  been  compelled  in  some  cases  to  rely  on  secondary 
sources  of  information.  The  number  of  such  cases  has  been  greatly 
reduced,  however,  through  the  kindness  of  colleagues,  friends,  and 
correspondents  who  were  appealed  to  for  suggestions,  criticisms,  and 
supplementary  material.  I  am  greatly  indebted  to  Prof.  Lafayette 
B.  Mendel,  of  the  Sheffield  Scientific  School  of  Yale  University,  for 
helpful  comments  and  detailed  criticism  of  the  whole  report,  and 
especially  of  those  parts  relative  to  the  physiology  of  nutrition;  to 
Prof.  Yandell  Henderson,  for  many  helpful  suggestions;  to  Prof. 
Henry  W.  Farnam,  for  suggestions  regarding  the  topics  of  industrial 
conditions;  to  Prof.  M.  V.  O'Shea,  of  the  University  of  Wisconsin, 
for  carefully  revising  the  major  part  of  the  section  on  school  hygiene; 
to  Dr.  Charles  Wardell  Stiles,  Chief  of  the  Division  of  Zoologyj 
Hygienic  Laboratory,  United  States  Public  Health  and  Marine- 
Hospital  Service,  for  information  on  the  extent  and  burden  of  the 
hook-worm  disease ;  to  Surg.  Gen.  Eobert  M.  O'Reilly,  of  the  United 
States  Army,  for  statistics  of  army  hygiene ;  to  Dr.  Prince  A.  Mor- 
row, of  New  York  City,  and  to  Prof.  C.  R.  Henderson,  of  the  Uni- 
versity of  Chicago,  for  carefully  prepared  notes  in  regard  to  "  the 
social  evil." 

I  am  indebted  to  Dr.  Herbert  E.  Smith,  dean  of  the  Yale  Medical 
School,  for  general  criticism ;  and  to  his  colleagues.  Profs.  Joseph  M. 
Flint,  George  Blumer,  H.  L.  Swain,  and  Oliver  T.  Osborne,  for 
criticism  and  aid,  both  general  and  special. 

Among  the  many  others  who  have  rendered  very  valuable  assist- 
ance I  would  especially  mention  Dr.  J.  H.  Townsend,  secretary  Con- 
necticut state  board  of  health;  Dr.  Cressy  L.  Wilbur,  Chief  of 
Division  of  Vital  Statistics,  Bureau  of  the  Census;  Col.  W.  C. 
Gorgas,  chief  sanitary  officer.  Isthmian  Canal  Commission ;  Dr.  J.  N. 
Hurty,  secretary  of  the  state  board  of  health  of  Indiana ;  Dr.  Charles 
V.  Chapin,  city  health  officer.  Providence,  R.  I. ;  Dr.  George  H.  Sim- 
mons, of  Chicago,  secretary  of  the  American  Medical  Association; 
Dr.  J.  N.  McCormack,  lecturer  of  the  American  Medical  Association ; 
Dr.  William  J.  Mayo,  formerly  president  of  the  American  Medical 
Association;  Dr.  Henry  P.  Walcott,  president  Massachusetts  state 


VTTT  REPORT    ON    NATIONAL  VITALITY. 

board  of  health ;  Prof.  F.  F.  Wesbrook,  dean  of  the  Medical  School 
of  the  University  of  Minnesota;  Dr.  Henry  B.  Baker,  ex-secretary 
Michigan  state  board  of  health;  Dr.  William  C.  Woodward,  health 
officer  of  the  District  of  Columbia;  Dr.  George  M.  Kober,  dean  of 
Georgetown  Medical  College;  Dr.  Norman  E.  Ditman,  of  Columbia 
University;  Dr.  J.  H.  Kellogg,  superintendent  of  the  Battle  Creek 
Sanitarium,  and  liis  assistants,  Dr.  J.  T.  Case  and  Dr.  W.  H.  Riley; 
Dr.  Richard  C.  Newton,  of  Montclair,  N.  J. ;  Dr.  Luther  H.  Gulick, 
of  New  York  City;  Dr.  W.  G.  Anderson,  director  Yale  gymnasium; 
Dr.  Charles  H.  Castle,  of  Cincinnati,  Ohio;  Dr.  J.  P.  C.  Foster,  of 
New  Haven;  Prof.  Russell  H.  Chittenden,  director  of  the  Sheffield 
Scientific  School  of  Yale  University;  Leo  F.  Rettger,  assistant  pro- 
fessor of  hygiene,  Yale  University ;  Dr.  George  M.  Gould,  of  Ithaca, 
N.  Y. ;  Dr.  Helen  C.  Putnam,  of  Providence,  R.  I. ;  F.  B.  Sanborn, 
of  Cambridge,  Mass. ;  Hiram  J.  Messenger,  actuary  of  the  Travelers 
Insurance  Company,  Hartford;  Mrs.  Ellen  H,  Richards,  of  the 
Massachusetts  Institute  of  Technology;  Mrs.  Frank  P.  Kinnicutt,  of 
New  York  City ;  and  William  H.  Tolman,  of  the  Museum  of  Safety 
and  Sanitation,  New  York  City. 

To  the  help  received  from  these  persons  will  be  due  in  large  measure 
whatever  of  value  this  report  may  have.  I  could  not,  single-handed, 
have  done  justice  to  even  a  portion  of  the  subject.  Except  for  a  few 
statistical  monographs  and  papers  cited  in  it,  I  have  contributed 
little  original  material.  It  has  been  my  task  to  interpret  material 
brought  together  from  many  sources.  Despite  all  the  aid  received,  I 
am  aware  that  the  report  abounds  in  sins  of  omission.  Great  pains 
have  been  taken  to  avoid  those  of  commission.  Doubtful  material 
has  been  eliminated  so  far  as  possible,  and  where  exact  figures  were 
unobtainable,  every  effort  has  been  made  to  see  that  the  statements 
made  should  be  cautious  and  conservative. 

For  aid  in  the  difficult  work  of  incorporating  into  the  manuscript 
the  numerous  suggestions  received,  I  am  indebted  to  Profs.  J.  Pease 
Norton,  William  B.  Bailey,  Fred  R.  Fairchild,  and  Dr.  L.  W.  Zart- 
man,  of  the  economic  department  of  Yale  University;  and  to  Dr. 
M.  M.  Scarborough,  of  the  Yale  Medical  School,  and  Dr.  F.  B. 
Standish,  of  New  Haven.  For  criticisms  on  the  form  of  presenta- 
tion, I  am  indebted  to  Mr.  Edwin  Bjorkman,  of  New  York  City; 
to  Mr.  Michael  Williams,  of  Oak  Bluffs,  Mass. ;  and  to  Mr.  Herbert 
A.  Smith,  of  the  U.  S.  Forest  Service. 

I  wish  to  thank  the  Interstate  Commerce  Commission  and  Prof. 
Henry  C.  Adams,  the  statistician  of  the  commission,  for  temporarily 
detailing  Mr.  Julius  H.  Parmelee,  a  member  of  the  Statistical  Division 
of  the  Interstate  Commerce  Commission,  to  the  work  of  compiling  the 
material  gathered  from  various  sources.  Mr.  Parmelee  has  brought  to 
his  work  an  unusual  equipment.  His  studies  have  been  not  only  in 
statistics,  but  also  in  hygiene.  Added  to  his  knowledge  he  has  en- 
thusiasm for  the  subjects  covered  and  a  keen  appreciation  of  their 
importance.  The  aid  which  he  has  rendered  has  been  much  more 
than  that  of  mere  calculator  and  compiler.  His  ability,  thoughtful- 
ness,  and  self-sacrificing  devotion  have  resulted  in  painstaking  work 
of  a  high  order,  without  which  the  report  could  not  have  been  written 
in  the  allotted  time. 

Irving  Fisher. 

Yale  Univeesity,  November,  1908. 


SUGGESTIONS  FOR  READERS. 

In  order  that  this  report  may  be  read  and  used  as  widely  as  pos- 
sible, it  has  been  arranged  with  reference  to  five  classes  of  readers : 

1.  The  "  Contents  by  sections  "  and  the  index  will  facilitate  the  use 
of  the  report  for  reference  purposes. 

2.  The  "  Abstract "  is  chiefly  intended  for  those  who  have  no  time 
to  read  more. 

3.  The  "  Summary  "  is  a  somewhat  fuller  resume. 

4.  The  "  Summary  "  is  also  designed  to  enable  those  who  so  desire 
to  read  some  parts  of  the  report  more  fully  than  others.  To  this  end 
the  "  Summary  "  is  arranged  to  correspond  to  the  main  report,  chap- 
ter by  chapter  and  section  by  section.  The  reader  who,  after  reading 
any  particular  part  of  the  "  Summary,"  wishes  to  read  the  corre- 
sponding part  of  the  main  report  has  only  to  turn  to  the  chapter  or 
section  having  the  same  number. 

5.  Those  who  read  the  entire  report  will  probably  prefer  to  read 
the  "  Summary  "  or  "  Abstract "  last. 

IX 


ABSTRACT. 

The  problem  of  conserving  natural  resources  is  only  one  part  of  the  larger 
problem  of  conserving  national  efficiency.  The  other  part  relates  to  the  vitality 
of  our  population.  The  two  parts  are  closely  interwoven.  Protection  against 
mining  accidents,  forest  fires,  floods,  or  pollution  of  streams  prevents  not  only 
loss  of  property,  but  loss  of  life.  The  prevention  of  disease,  on  the  other  hand, 
increases  economic  productivity. 

So  far  as  we  can  compare  vital  and  physical  assets  as  measured  by  earning 
power,  the  vital  assets  are  three  to  five  times  the  physical.  The  facts  show 
that  there  is  as  great  room  for  improvement  in  our  vital  resources  as  in  our 
lands,  waters,  minerals,  and  forests.  This  improvement  is  possible  in  respect 
both  to  the  length  of  life  and  to  freedom  from  disease  during  life. 

Contrary  to  common  impression,  there  is  no  iron  law  of  mortality.  Recent 
statistics  for  India  show  that  the  average  duration  of  life  there  is  less  than 
twenty-five  years.  In  Sweden  it  is  over  fifty  years,  in  Massachusetts  forty-five 
years.  The  length  of  life  is  increasing  wherever  sanitary  science  and  prevent- 
ive medicine  are  applied.  In  India  it  is  stationary.  In  Europe  it  has  doubled 
in  three  and  a  half  centuries.  The  rate  of  increase  during  the  seventeenth  and 
eighteenth  centuries  was  about  four  years  per  century,  during  the  first  half  of 
the  nineteenth  century  about  nine  years  per  century,  during  the  latter  half  of 
the  nineteenth  century  about  seventeen  years  per  century,  and  in  Germany, 
where  medical  and  sanitary  science  has  reached  the  highest  development,  about 
twenty-seven  years  per  century.  The  only  comparative  statistics  available  in 
this  country  are  for  Massachusetts,  where  life  is  lengthening  at  the  rate  of 
about  fourteen  years  per  century,  or  half  the  rate  in  Germany. 

There  is  no  need,  however,  of  waiting  a  century  for  this  increase.  It  could 
be  obtained  within  a  generation.  Three-fourths  of  tuberculosis,  from  which 
150,000  Americans  die  annually,  could  be  avoided.  Eighteen  experts  in  various 
diseases,  as  well  as  vital  statisticians,  have  contributed  data  on  the  ratio  of 
preventability  of  the  ninety  different  causes  of  death  into  which  mortality 
may  be  classified.  From  these  data  it  is  found  that  fifteen  years  at  least  could 
be  at  once  added  to  the  average  human  lifetime  by  applying  the  science  o^ 
preventing  disease.  More  than  half  of  this  additional  life  would  come  from  the 
prevention  of  tuberculosis,  typhoid,  and  five  other  diseases,  the  prevention  of 
which  could  be  accomplished  by  purer  air,  water,  and  milk.  In  Lawrence, 
Mass.,  after  the  installation  of  a  pure-water  supply,  the  death  rate  from  typhoid 
was  reduced  by  80  per  cent.  For  every  death  thus  saved  from  typhoid,  twf 
or  three  deaths  are  saved  from  other  diseases. 

Judging  from  the  English  statistics  of  illness,  we  must  conclude  that  at  ah 
times  in  the  United  States  about  3,000,000  persons  are  seriously  ill,  of  whon. 
about  500,000  are  consumptives.     Fully  half  of  this  illness  is  preventable. 

If  we  appraise  each  life  lost  at  only  $1,700  and  each  year's  average  earnings, 
for  adults  at  only  $700,  the  economic  gain  to  be  obtained  from  preventing  pre- 
ventable disease,  measured  in  dollars,  exceeds  one  and  a  half  billions.  This 
gain,  or  the  lengthening  and  strengthening  of  life  which  it  measures,  can  be 
secured  through  medical  investigation  and  practice,  school  and  factory  hygiene, 
restriction  of  labor  of  women  and  children,  th6  education  of  the  public  in  both 
public  and  private  hygiene,  and  through  improving  the  efficiency  of  our  munic- 
ipal, state,  and  national  health  service.  Our  National  Government  has  now 
several  bureaus  exercising  health  functions,  which  only  need  to  be  concentrated 
under  one  department  to  become  coordinated  parts  of  a  greater  health  service 
worthy  of  the  nation. 

1 


SUMMARY. 
Summary  of  Part  I. — Length  of  life  versus  mortality. 

SUMMARY  OF  CHAPTER  I THE  LENGTH  OF  LIFE. 

Section  1.  In  different  places. — President  Roosevelt  lias  pointed  out  tliat  the 
problem  of  conserving  our  natural  resources  is  part  of  another  and  greater  prob- 
lem—that of  national  efficiency.  This  depends  not  only  on  physical  environment, 
but  on  social  environment,  and  most  of  all  on  human  vitality.  Modern  hygiene 
is  the  reaction  against  the  old  fatalistic  creed  that  deaths  inevitably  occur  at  a 
constant  rate.  The  new  motto  is  that  of  Pasteur :  "  It  is  vs^ithin  the  power  of 
man  to  rid  himself  of  every  parasitic  disease." 

It  was  once  believed  that  human  mortality  followed  an  "  inexorable  law." 
Facts,  however,  show  that  mortality  varies  in  different  places  and  is  decreasing 
as  hygiene  comes  into  use.  The  length  of  life  in  Sweden  and  Denmark  is  over 
(ifty  years ;  in  the  United  States  and  England  about  forty-five ;  in  India  less  than 
twenty-five. 

Sec.  2.  At  different  times. — In  Europe,  according  to  one  authority,  the  length 
of  life  has. increased  in  three  hundred  and  fifty  years  from  less  than  twenty  to 
about  forty  years ;  in  England,  in  less  than  half  a  century,  it  has  increased  about 
five  years;  in  Prussia,  in  the  last  quarter  of  a  century,  over  six  years;  in 
America  it  has  also  increased,  although  good  life  tables  are  lacking  excepting 
for  insurance  experience.  The  tables  for  Massachusetts  for  1893-1897  show  an 
average  duration  of  life  in  that  State  of  forty-five  years,  as  compared  with  forty 
in  1855,  and  thirty-five,  an  estimate  of  1789,  based,  however,  on  doubtful  returns. 

SUMMARY  OF  CHAPTER  II — THE  MORTALITY  RATE. 

Section  1. — Relation  of  longevity  to  mortality. — As  duration  of  life  increases 
the  death  rate  decreases.  A  death  rate  is  the  ratio  of  the  number  of  deaths  in 
a  year  to  the  population.  Under  normal  conditions  where  the  population  is 
"  stationary  " — that  is,  neither  increasing  nor  decreasing  nor  subject  to  immigra- 
tion or  emigration — the  death  rate  and  the  duration  of  life  are  "  reciprocals." 
In  such  a  population,  if  the  death  rate  is  20  per  1,000,  the  duration  of  life  will  be 
1,000-^20=50  years. 

This  relation,  however,  is  disturbed  in  most  countries  to-day,  and  especially  in 
America,  by  immigration  and  emigration  and  by  the  birth  rate  being  in  excess 
i)f  the  death  rate.  Nevertheless,  death  rates,  if  compared  under  similar  condi- 
tions, furnish  a  fairly  good  index  of  vitality.  They  vary  in  different  places  and 
ut  different  times. 

Sec.  2.  Mortality  in  various  regions. — In  the  registration  area  of  the  United 
States  the  death  rate  is  16.5  per  1,000 ;  in  France  it  is  20 ;  in  India  42.  In  dif- 
ferent States  of  the  United  States  it  varies  from  14  in  Michigan  to  18  in  New 
York. 

Sec.  3.  Urban  and  rural  mortality. — The  death  rate  is  higher  in  the  city  than 
in  the  country,  and  the  larger  the  city  the  higher  the  death  rate.  In  European 
countries  among  the  cities  with  the  highest  death  rate  are  Dublin  (40)  and 
Moscow  (37)  ;  among  the  lowest,  Frankfort  on  the  Main  (16)  and  The 
Hague  (16). 

Sec.  4.  Race  and  condition. — The  colored  death  rate  greatly  exceeds  the  white. 
The  death  rate  among  the  poor  exceeds  that  among  the  rich,  being  in  Glasgow 
and  Paris  over  twice  as  great. 

Sec.  5.  Mortality  historically. — Death  rates  have  been  decreasing  during  sev- 
eral centuries.  In  London,  where  now  the  death  rate  is  only  15,  it  was  during 
the  seventeenth  and  eighteenth  centuries  40  to  50,  and  during  1680  to  1728,  a 
period  of  pests,  it  rose  as  high  as  80.  Similar  reduction  has  also  been  experi- 
enced in  this  country.  In  Habana  the  death  rate  after  the  American  occupa- 
tion fell  from  over  50  to  about  20. 


KEPORT    ON    NATIONAL   VITALITY.  3 

Sec.  6.  Adult  and  infant  mortality. — The  greatest  reduction  has  been  effected 
among  children,  although  the  death  rate  is  still  undoubtedly  high.  Statistics 
show  that  during  the  last  thirty  years  the  death  rate  up  to  50  years  of  age  has 
decreased,  but  that  beyond  50  it  has  remained  almost  stationary. 

Sec.  7.  Particular  diseases. — The  mortality  from  certain  special  diseases  has 
greatly  decreased.  The  tuberculosis  death  rate  is  now  in  England  only  one- 
third  of  what  it  was  seventy  years  ago.  The  death  rate  from  pneumonia  now 
equals  that  of  tuberculosis.  Typhoid  fever  is  decreasing.  In  Munich  during 
1856  the  mortality  was  291  per  100,000  of  population.  The  city  at  that  time 
contained  many  cesspools.  After  these  were  filled  up  the  typhoid  rate  fell  to  10 
per  100,000  in  1SS7,  making  a  reduction  of  97  per  cent.  In  Lawrence,  Mass., 
after  the  public  water  was  filtered  in  1893  the  typhoid-fever  rate  fell  from  105 
to  22.  Doctor  Kober  has  shown  that  death  rates  from  typhoid  fever  are  great- 
est in  cities  in  which  the  rivers'  waters  are  polluted,  the  average  for  these 
cities  being  62,  as  compared  with  18  for  cities  using  unpolluted  water  of 
impounded  and  conserved  streams.  Doctor  Rosenau  concludes  that  any  com- 
munity having  clean  water  and  uninfected  milk  supply  may  be  free  from 
typhoid. 

Smallpox  has  greatly  decreased  since  vaccination  has  been  employed.  In 
Prussia  the  death  rate  per  100,000  from  smallpox  between  1846  and  1870  was 
24.  In  1874  vaccination  was  made  compulsory,  and  the  death  rate  for  the  years 
3875-76  fell  to  1.5.  Similar  figures  can  be  given  for  other  places.  The  present 
outcry  against  vaccination  is  based  on  misinformation  and  on  the  general  rea- 
soning that  it  is  unnatural  to  introduce  a  poison  into  the  blood.  Statistics  show 
clearly  that  vaccination  decreases  smallpox  and  lengthens  life.  Even  though  it 
were  shown  that  the  virus  is  injurious,  it  would  be  the  lesser  of  two  evils. 

Yellow  fever  in  Philadelphia  in  1793  caused  the  death  of  one-tenth  of  the 
city's  population  within  six  and  one-half  weeks.  In  1900  it  was  found  that  a 
species  of  mosquito  transmits  this  disease.  The  result  of  this  applied  knowl- 
edge is  that  the  disease  has  practically  disappeared  in  America. 

Summary  of  Paet  II. — Breadth  of  life  versus  invalidity. 

SUMMARY  OF   CHAPTER  III — PREVALENCE   OF    SERIOUS   ILLNESS. 

Section  1.  Loss  of  time. — Life  is  shortened  by  death,  and  narrowed  by  inva- 
lidity. The  ideal  life,  with  respect  to  health,  would  be  free  from  illness  and  dis- 
ability of  every  kind.  To  approximate  such  an  ideal  is  the  aim  of  hygiene.  It 
is  usually  true  that  the  healthier  a  life  the  longer  it  will  last.  Humboldt  main- 
tained that  he  had  lived  four  working  lives  by  retaining  a  working  power  double 
the  average  for  double  the  average  number  of  j-ears.  According  to  Farr,  for 
every  death  there  is  an  average  severe  sickness  of  two  years,  or  for  each  death 
per  year  there  are  two  persons  sick  throughout  the  year.  This  would  mean  in 
the  United  States  that,  as  there  are  about  1,500,000  annual  deaths,  there  will 
always  be  about  8,000^000  persons  on  the  sick  list,  which  is  equivalent  to  about 
thirteen  days  per  capita. 

Sec.  2.  Particular  diseases. — There  are  constantly  ill  in  the  United  States  of 
tuberculosis  about  500,000  persons,  of  whom  about  one-half  are  totally  incapac- 
itated, while  the  remainder  are  half  incapacitated.  The  causes  of  various 
diseases  are  closely  interwoven.  Professor  Sedgwick  tells  us  that  "  Hazen's 
theorem  "  shows  for  every  death  from  typhoid  fever  avoided  by  the  purification 
of  a  polluted  water  supply  two  or  three  deaths  are  avoided  from  other  causes. 
Hook-worm  disease  in  the  South  is  a  chief  cause  of  incapacitation,  especially 
among  the  poor  whites.  For  this  reason  the  hook  worm  has  been  nicknamed  the 
"germ  of  laziness."  It  is  believed  that  a  sufferer  from  hook-worm  disease  is 
incapacitated  from  one-fourth  to  one-half  of  the  time. 

The  number  of  syphilitics  in  the  United  States  has  been  estimated  at  2,000,000, 
though  from  the  nature  of  the  case  this  figure  is  chiefly  conjecture.  The  social 
diseases,  syphilis  and  gonorrhea,  are  responsible  for  the  existence  of  a  large 
proportion  of  defectives  of  various  kinds  which  fill  our  institutions.  Among  the 
troops  in  the  Philippines  the  venereal  morbidity,  during  the  year  1904,  was  297 
per  1,000,  largely  exceeding  the  morbidity  from  malarial  fevers  and  diarrhea,  as 
22  out  of  every  1,000  soldiers  were  constantly  ineffective  from  venereal  disease — 
four  times  as  many  as  from  any  other  disease.  The  statistics  outside  of  army 
and  navy  service  are  impracticable,  but  there  is  some  reason  to  believe  that  they 
might  show  an  even  larger  morbidity.  The  social  diseases,  which  certainly  are 
preventable,  are  one  of  the  gravest  of  the  menaces  to  national  efiiciency. 


4  EEPORT   ON   NATIONAL  VITALITY. 

AmericaB  railways  in  1907-8  killed  nearly  11,800  and  injured  nearly  111,000 
persons.  The  deaths  and  disablements  from  accidents  in  industry,  although 
less  carefully  recorded,  also  represent  a  great  and  needless  impairment  of 
efficiency. 

SUMMARY    OF    CHAPTER    IV — PREVALENCE    OF    MINOR    AILMENTS. 

Section  1.  Importance  of  minor  ailm,ents. — Minor  ailments  are  far  more  com- 
mon than  most  persons  realize.  They  are  chiefly  functional  disorders,  such  as  of 
the  stomach,  heart,  nerves,  liver,  kidney,  etc.  These  deserve  more  attention 
than  they  have  hitherto  received,  because  they  are  the  gatevray  to  more  serious 
troubles.  For  instance,  those  who  neglect  colds,  or  what  seem  to  be  colds, 
will  be  far  more  likely  to  become  victims  of  tuberculosis  or  pneumonia.  No 
statistics  of  the  prevalence  of  minor  ailments  exist.  Physicians,  whose  experi- 
ence gives  them  good  opportunity  to  judge,  place  the  time  lost  annually  for  each 
person  from  minor  ailments  at  three  or  more  days  a  year. 

Sec.  2.  PreventaMUty  of  m,inor  ailments. — Practically  all  minor  ailments 
can  be  avoided  by  proper  hygiene,  public  and  private.  Neurasthenia,  so  common 
in  America,  is  one  of  the  most  serious  and  insidious  introductions  to  grave 
disorders,  and  is  usually  due  to  needless  worry  or  failure  to  have  adequate 
recreation. 

SUMMARY    OF    CHAPTER   V — PREVALENCE    OF    UNDUE    FATIGUE. 

Section  1.  Strength,  endurance,  and  fatigue. — Strength  is  measured  by  the 
force  a  muscle  can  exert  once ;  endurance  by  the  number  of  times  it  can  repeat 
an  exertion  requiring  a  specified  part  of  the  strength.  Fatigue  is  a  chemical 
effect,  due  to  "  fatigue  poisons."  Far  greater  differences  exist  between  differ- 
ent persons  in  respect  to  endurance  than  in  respect  to  strength.  Some  "  well " 
people  become  tired  by  a  short  walk,  while  others  withstand  hours  of  walk- 
ing, running,  or  climbing. 

Sec.  2.  Alcohol  and  fatigue. — The  "  Committee  of  Fifty  "  found  that  alcohol 
gives  no  persistent  increase  of  muscular  power.  It  is  well  understood  by  all 
who  control  large  bodies  of  men  engaged  in  physical  labor  that  alcohol  and 
effective  work  are  incompatible.  Rivers,  writing  on  the  influence  of  alcohol  on 
fatigue,  found  that  when  workmen  were  provided  with  a  moderate  amount  of 
wine  it' resulted  in  a  considerable  diminution  of  their  capacity  for  work. 

Sec  3.  Tobacco  and  fatigue. — Athletes  recognize  that  smoking  interferes 
with  one's  "  wind  "  or  "  staying  power."  "  Inhaling  "  tobacco  smoke  brings 
carbon-monoxide  directly  into  the  blood  stream.  It  is  found  that  smoking  in- 
creases blood  pressure,  which  fact  possibly  partly  explains  the  reduction  in 
endurance. 

Sec.  4.  Diet  and  fatigue. — When  excessive  amounts  of  the  protein  element 
in  food  (exemplified  in  white  of  egg  or  the  lean  part  of  meat)  are  taken,  they 
putrefy  in  the  large  intestine,  producing  "  auto-intoxication."  For  this  and 
other  reasons,  there  is  a  present  tendency  among  physiologists  to  advise  a 
reduction  in  the  use  of  such  foods  from  the  amounts  customary  in  many  coun- 
tries, and  especially  in  the  United  States.  Auto-intoxication  induces  fatigue. 
The  endurance  of  those  using  high  protein  and  of  those  using  low  protein  shows 
in  general,  although  with  some  exceptions,  that  the  former  have  less  endurance 
than  the  latter.  Whether  the  latter  are  vegetarian  or  not  does  not  seem  to 
matter.  Experiments  show  that  thorough  mastication  leads  instinctively  to  a 
reduction  in  protein. 

Sec.  5.  Exertion  and  fatigue. — Oxygen,  whether  taken  naturally  or  artificially, 
increases  the  capacity  for  exertion.  A  judicious  amount  of  exercise  is  per- 
haps the  chief  factor  in  producing  the  highest  state  of  muscular  efficiency. 
Physical  training,  comprising  exercise  and  other  hygienic  measures,  will  prob- 
ably make  the  capacity  to  withstand  great  exertion  three  or  four  times  that 
possessed  by  most  persons. 

Sec  6.  The  working  day. — The  present  working  day,  from  a  physiological 
standpoint,  is  too  long,  and  keeps  the  majority  of  men  and  women  in  a  con- 
tinual state  of  overfatigue.  It  starts  a  vicious  circle,  leading  to  the  craving 
of  means  for  deadening  fatigue,  'thus  inducing  drunkenness  and  other  excesses. 
Experiments  in  reducing  the  working  day  show  a  great  improvement  in  the 
physical  efficiency  of  laborers,  and  in  many  cases  results  in  even  increasing 
their  output  sufficiently  to  compensate  the  employer  for  the  shorter  day.    Several 


EEPORT   ON   NATIONAL  VITALITY.  5 

examples  of  such  a  result  exist,  but  the  real  justification  for  a  shorter  work  day 
is  found  in  the  interest  of  the  race,  not  the  employer.  One  company,  which 
keeps  its  factory  going  night  and  day,  found,  on  changing  from  two  shifts  of 
twelve  hours  each  to  three  shifts  of  eight  hours  each,  that  the  efficiency  of  the 
men  gradually  increased,  and  the  days  lost  per  man  by  illness  fell  from  seven 
and  one-half  to  five  and  one-half  per  year.  Public  safety  requires,  in  order  to 
avoid  railway  collisions  and  other  accidents,  the  prevention  of  long  hours,  lack 
of  sleep,  and  undue  fatigue  in  workmen. 

Sec.  7.  The  importance  of  preventing  undue  fatigue. — The  economic  waste 
from  undue  fatigue  is  probably  much  greater  than  the  waste  from  serious  ill- 
ness. This  is  because  the  number  of  fatigued  persons  is  great  enough  to  more 
than  outweigh  the  fact  that  the  incapacitation  from  fatigue  is  relatively  small. 
Moreover,  the  relatively  slight  impairment  of  efficiency  due  to  overfatigue  leads 
to  greater  impairment  from  serious  illness.  A  typical  succession  of  events  is, 
first,  fatigue,  then  "  colds,"  then  tuberculosis,  then  death.  The  prevention  of 
undue  fatigue  means  the  arrest  at  the  start  of  this  accelerating  chain  of 
calamities. 

Summary  of  Paet  III. — Methods  of  conserving  life. 

SUMMAEY   OF   CHAPTEB   VI — CONSERVATION   THROUGH    HEREDITY. 

Section  1.  Heredity  and  environment. — A  wise  and  farsighted  economy  will 
lead  the  nation  to  conserve  its  vital  resources  by  every  possible  method.  These 
resources  depend  on  two  primary  conditions,  heredity  and  hygiene,  or  conditions 
preceding  birth  and  conditions  during  life.  In  other  words,  vitality  is  partly 
inherited  and  partly  acquired.  A  sound  physical  and  mental  inheritance  is  a 
greater  asset  than  the  inheritance  of  extraneous  advantages  like  wealth.  Even 
in  the  Old  World  a  degenerate  nobility  in  the  end  receives  less  respect  than  a 
virile  middle  class.  The  effort  to  improve  vitality  reaches  its  highest  point  in  a 
nation  when  its  health  ideals  affect  marriage. 

Sec.  2.  Eugenics. — Galton,  Pearson,  and  others  are  attempting  to  found  the 
new  science  of  "  eugenics,"  by  which  is  not  meant  any  scheme  of  general  govern- 
mental interference  with  marriage,  but  the  gradual  establishment  in  public 
opinion  of  fundamental  standards.  Just  as  to-day  the  marriage  of  brother  and 
sister  is  unthinkable,  Galton  suggests  that  the  time  may  come  when  marriage 
which  obviously  promotes  degeneration  will  be  equally  tabooed.  The  result 
would  be,  not  to  make  marriage  more  artificial,  but  less.  Health,  beauty,  and 
vitality  are  much  more  natural  objects  of  youthful  admiration  than  titles  or 
wealth,  which  now  exercise,  for  the  most  part,  a  baneful  influence  on  marriage. 
To  lessen  the  esteem  for  those  false  attractions  and  increase  that  for  natural 
attractions  will  tend  not  only  to  increase  the  number  of  healthy  marriages,  but 
to  give  greater  importance  to  natural  and  normal  love.  The  effect  will  be  felt 
both  in  bringing  about  a  larger  proportion  of  marriages  among  the  healthy  and 
a  smaller  proportion  among  the  unhealthy.  It  will  also  lead  to  a  partial  segre- 
gation by  which  the  healthy  will  to  a  large  extent  marry  among  themselves,  and 
thus  leave  the  unhealthy  either  unmarried  or  compelled  to  make  alliances  in 
their  own  class.  The  result  will  be,  in  the  struggle  for  race  supremacy,  that 
the  healthy,  thus  separated  off  from  the  relatively  unfit,  will  have  a  distinct 
advantage  both  in  the  number  of  offspring  and  in  their  vitality. 

Sec.  3.  Eugenics  and  law. — The  only  government  influences  which  have  been 
seriously  suggested  by  eugenists  are  two:  First,  the  offering  of  prizes  or 
bounties  to  couples  who  conform  to  certain  standards,  in  the  same  way  as  the 
French  Government  has  encouraged  the  increase  of  its  population  by  offering 
inducements  to  couples  of  the  poorer  class  who  raise  seven  or  more  children ; 
second,  to  prevent  marriage  alliances  among  criminals,  paupers,  and  the  feeble- 
minded. Some  laws  on  these  subjects  already  exist  in  Connecticut,  Michigan, 
and  especially  Indiana,  where  there  is  a  prohibition  of  marriage  of  all  persons 
suffering  from  transmissible  diseases.  It  is  also  now  provided  in  Indiana  that 
confirmed  criminals,  imbeciles,  and  rapists,  when  it  is  deemed  advisable  by 
experts,  shall  be  unsexed.  What  such  laws  might  accomplish  may  be  judged 
from  the  history  of  two  criminal  families,  the  "  Jukes "  and  the  "  Tribe  of 
Ishmael."  Out  of  1,200  descendants  from  the  founder  of  the  "  Jukes  "  through 
seventy-five  years,  310  were  professional  paupers,  who  spent  in  all  two  thousand 
three  hundred  years  in  poorhouses,  50  were  prostitutes,  7  murderers,  60  habitual 
thieves,  and  130  common  criminals.     The  loss  of  potential  usefulness,  cost  of 


6  REPOET   ON   NATIONAL  VITALITY. 

prosecutions,  expense  of  maintenance  of  jails,  etc.,  Dugdale  estimated  to  be 
$1,300,000  in  seventy-five  years,  or  over  $1,000  for  each  member  of  the  family. 
All  these  unfortunate  results  could  have  been  avoided  had  the  original  criminals 
in  this  family  been  sterilized  under  a  law  like  that  of  Indiana. 

We  have  the  more  agreeable  record  of  excellent  human  qualities  inherited 
through  successive  generations  in  the  Darwin,  Hohenzollern,  and  other  families. 

SUMMABY    OF    CHAPTER   VII — CONSERVATION    THROUGH    PUBLIC    HYGIENE. 

Section  1.  Municipal  hygiene. — The  benefits  of  improved  heredity  can  be  en- 
joyed only  by  future  generations.  But  we  of  the  present  day  may  conserve  our 
vital  resources  through  hygiene,  practiced  in  one  or  all  of  three  ways — public, 
semipublic,  and  personal  hygiene.  The  first  refers  to  governmental  regulation 
of  health,  the  second  to  the  professional  or  institutional  care  of  health,  and  the 
third  to  the  private  life  of  the  individual  and  the  family.  Every  city  now  has 
its  health  board,  yet  few  citizens  realize  that  the  protection  rendered  by  these 
boards  is  more  important  than  the  protection  by  the  police  or  fire  departments. 
Much  as  is  done  by  these  boards,  there  is  enormous  room  for  improvement,  both 
in  making  regulations  and  in  enforcing  them  by  the  aid  of  a  more  enlightened 
public  opinion.  The  abatements  of  the  nuisance  and  menace  from  spitting  and 
from  vitiation  by  smoke  are  cases  in  point.  Pure  air  is  one  of  the  primary 
necessaries  of  life,  but  only  a  small  fraction  of  our  countrymen  actually  enjoy 
this  boon.  To  this  end  proper  drainage  and  garbage  removal  and  clean  streets 
are  needed.  The  transmission  of  disease  by  insects,  flies,  and  vermin  needs  to 
be  checked.  A  constant  cause  of  mortality,  among  infants  especially,  is  an  im- 
pure milk  supply.  The  same  danger  exists  in  other  dairy  products,  cream, 
butter,  cheese,  and  ice  cream.  In  Washington,  owing  apparently  to  the  enact- 
ment of  a  law  in  1895  regulating  the  sale  of  milk,  the  death  rate  from  diarrhea 
and  inflammation  of  the  bowels  among  children  under  2  years  of  age  was  re- 
duced from  160  or  170  to  135,  then  109,  104,  and  in  1906  to  97.  Similar  reports 
come  from  many  other  cities  in  this  country  and  abroad. 

Sec.  2.  State  hygiene. — The  regulation  of  the  labor  of  women  and  children 
is  usually  a  state  matter.  It  has  been  suggested  by  Doctor  Stiles  that  every 
woman  should  be  allowed  once  a  month  to  leave  a  factory  without  being  asked 
questions  or  losing  wages.  The  employment  of  mothers  before  and  after  child- 
birth should  be  prohibited,  as  it  is  now  in  a  number  of  European  countries. 
This  single  reform  would  help  greatly  to  conserve  the  vitality  of  the  next 
generation.  Child  labor  in  the  South  is  in  many  cases  the  lesser  of  two  evils, 
the  other  being  exposure  to  the  hook-worm  disease  on  polluted  farms.  In 
these  cases,  the  abolition  of  child  labor  should  be  preceded  by  the  abolition  of 
hook-worm  disease.  Hours  of  labor  have  been  steadily  decreasing,  and  should 
be  decreased  further.  Accidents  are  unnecessarily  frequent  on  our  American 
railroads,  as  well  as  in  industrial  establishments.  Statistics  do  not  exist  for 
the  latter.  Special  trades  have  special  dangers.  Among  such  trades  are  those 
using  lead  and  other  dangerous  poisonous  chemicals,  as  well  as  the  dust- 
producing  trades  which  tend  to  pulmonary  troubles.  The  dark  room  tenements 
are  a  common  means  in  our  large  cities  of  depleting  national  vitality. 

Sec.  3.  Federal  hygiene. — This  includes  quarantine,  the  inspection  of  im- 
migrants and  exclusion  of  those  with  infectious  diseases,  administration  of 
government  hospitals,  of  pure-food  laws  and  meat  inspection,  and  cooperation 
with  state  boards  of  health  in  fighting  yellow  fever,  bubonic  plague,  etc. 
Federal  power  needs  extension,  however.  Our  interstate  railroads  should  be 
improved  in  respect  to  the  sanitation  of  sleeping  cars,  smoking  cars,  etc. 

The  movement  to  secure  a  more  intelligent  national  organization  of  health 
is  now  being  pushed  by  the  President,  President-Elect,  and  Members  of  Con- 
gress, and  has  found  expression  in  the  recent  platforms  of  both  political  parties. 
What  is  needed  is  that  the  Federal  Government  should  make  the  national 
capital  a  model  of  sanitation,  should  provide  for  more  investigation  in  health 
matters  and  the  dissemination  of  information  on  the  prevention  of  tuberculosis, 
etc.,  should  cooperate  further  with  state  and  municipal  authorities,  and  should 
check  the  pollution  of  interstate  streams  and  prevent  the  transmission  of  dis- 
ease-bearing meats  or  other  food  from  one  State  to  another.  Lastly,  it  should 
secure,  through  whatever  constitutional  means  exist,  some  method  of  collecting 
statistical  information  as  to  our  national  mortality  and  morbidity.  Our  short- 
comings in  this  respect  are  now  a  national  disgrace.  There  is  no  accurate 
record  of  births  in  any  part  of  the  United  States,  and  that  of  deaths  includes 
less  than  half  our  population.    As  a  statistician  has  said  of  one  of  the  States, 


EEPORT   ON   NATIONAL  VITALITY.  7 

"  It  buries  its  dead  people  with  no  more  ceremony  than  it  buries  its  dead  dogs." 
Obviously,  no  intelligent  control  of  epidemics  and  other  diseases  can  be  made 
unless  the  facts  in  regard  to  those  diseases  are  known ;  in  other  words,  unless 
there  exist  mortality  and  morbidity  statistics  of  real  value. 

SUMMARY  OF    CHAPTER   VIII — CONSERVATION   THROUGH    SEMIPUBLIC    HYGIENE. 

Section  1.  Medical  research  and  instruction. — Semipublic  hygiene  comprises 
that  relating  to  institutions  and  the  medical  profession.  The  hygiene  of  the  future 
must  depend  more  on  discoveries  in  preventive  medicine  than  on  any  other 
single  factor,  and  institutions  such  as  the  Pasteur  Institute,  the  Rockefeller 
and  the  Carnegie  institutes,  and  the  research  laboratories  of  the  Government 
and  universities  offer  the  most  promising  means  of  increasing  this  most  useful 
and  practical  of  all  human  knowledge.  The  knowledge  is  dispensed  through 
medical  schools  in  the  training  of  physicians.  These  schools  are  improving  so 
as  to  introduce  more  of  hygiene  and  preventive  medicine.  We  are  still  far, 
however,  from  having  facilities  for  training  public  health  officers,  or  giving 
them  such  a  degree  as  D.  P.  H.  (diploma  of  public  health),  as  is  given  in 
England. 

Sec,  2.  The  medical  profession. — Antiseptic  surgery  has  in  the  last  century 
been  the  greatest  triumph  of  the  medical  profession,  and  has  given  it  a  greater 
prestige  than  ever  before.  It  has  greatly  reduced  the  mortality  from  opera- 
tions, and  is  illustrated  by  the  figures  in  army  operations.  The  mortality  of  the 
wounded  in  the  Crimean  war  among  English  troops  was  15  per  cent.  The 
mortality  in  the  Transvaal  war,  1900-1901,  was  less  than  6  per  cent. 

In  the  practice  of  medicine,  the  tendency  is  progressively  to  give  up  the  use 
of  violent  drugs  and  to  depend  more  on  hygiene.  Through  the  modern  fight 
against  tuberculosis,  physicians  have  come  to  prescribe  fresh  air  in  their  prac- 
tice generally.  They  are  now  turning  in  like  manner  to  exploit  the  resources 
of  diet,  exercise,  bathing,  and  mental  hygiene. 

Thei-e  is  danger  that  these  new  fields  will  be  preempted  by  quacks.  Many 
quacks  to-day,  far  from  using  patent  medicines,  oppose  the  use  of  any  drugs 
whatever.  In  order  that  modern  hygiene  shall  be  applied  by  trained  physicians, 
it  is  necessary  that  they  provide  more  facilities  in  this  direction.  The  leaders 
of  the  profession  are  making  every  effort  to  raise  all  members  of  their  profes- 
sion to  their  own  high  standard.  This  standard  not  only  aims  to  prevent  mal- 
practice and  unethical  operations,  but  to  set  an  example  to  the  people  in  public 
service  and  in  personal  hygienic  living. 

Sec.  3.  Institutional  hygiene. — Hospitals  have  done  much  to  prevent  disease 
by  segregating  infectious  cases.  Institutions  for  the 'deaf  and  blind  and  other 
defectives  have  led  to  a  better  utilization  of  their  powers.  Institutional  care  of 
the  insane  has  done  much,  too,  but  can  do  more.  Mental  hygiene  as  a  whole  needs 
to  be  more  carefully  studied  and  taught  in  all  its  relations — heredity,  alcohol, 
syphilis,  and  environment. 

The  modern  sanitarium  has  become  a  useful  institution  for  prevention  of 
serious  illness,  as  distinct  from  the  hospital,  of  which  the  function  has  been  to 
cure.  Department  stores,  hotels,  and  other  commercial  institutions  are  install- 
ing ventilating  and  other  hygienic  apparatus.  The  churches  are  also  taking 
part  in  the  health  movement,  especially  the  Emmanuel  Church  in  Boston. 

Sec.  4.  School  hygiene. — The  hygiene  of  school  children  is  especially  impor- 
tant because  of  its  application  to  human  life  in  its  early  stages.  There  is  a 
world-wide  movement,  led  by  Switzerland  and  some  other  countries  of  Europe, 
to  obtain  and  apply  knowledge  of  how  to  educate  the  mind  without  weakening 
the  body.  As  it  is,  school  children  are  especially  exposed  to  contagious  dis- 
eases, which  under  present  conditions  often  sweep  through  a  whole  school  be- 
fore the  local  health  board  even  hears  of  it.  Quite  as  serious,  if  not  more  so,  is 
the  protecting  of  school  children  from  imperfect  seating,  lighting,  ventilation, 
and  sanitation. 

Backward  children,  with  defects  of  eye,  ear,  nose,  or  throat,  are  numerous, 
but  experiments  have  shown  that  the  majority  could  be  improved  both  in  intel- 
lect and  in  morals. 

In  respect  to  school  hygiene,  it  is  not  so  much  lack  of  knowledge  as  lack  of 
application  of  knowledge  which  is  at  fault.  In  order  to  find  and  then  correct 
defects  of  eyes,  ears,  teeth,  etc.,  and  properly  apply  our  knowledge,  medical 
inspection  is  necessary.  Such  inspections  as  have  been  made  disclose  an 
astonishing  amount  of  ill  health,  the  percentage  of  morbidity  being  from  20  to 
60  per  cent.     The  committee  on  physical  welfare  of  school  children  in  New 

84369— No.  30—09 2 


8  REPORT   ON   NATIONAL  VITALITY. 

York  found  that  66  per  cent  needed  medical  or  surgical  attention  or  better 
nourishment;  40  per  cent  needed  dental  care;  38  per  cent  had  enlarged  glands 
of  the  neck ;  31  per  cent  had  defective  hearing ;  18  per  cent  had  enlarged  tonsils. 

Eye  strain  is  a  particular  evil  of  civilization,  and  makes  its  first  appearance 
in  school  when  the  scholar  tries  to  accommodate  the  eye  to  the  short  range 
which  reading  requires,  but  for  which  the  eye  mechanism  is  not  well  adapted 
by  nature.  The  evil  effects  of  eye  strain  are  not  confined  to  that  organ,  but  ex- 
tend to  the  whole  nervous  system,  and  indirectly  to  the  whole  organism. 
Doctor  Gould,  who  has  made  a  special  study  of  this  subject,  goes  so  far  as  to 
maintain  that  "  eye  strain  is  the  chief  source  of  the  functional  diseases  of  our 
citizens." 

At  present  medical  inspection  is  the  exception  rather  than  the  rule.  Only  70 
cities  in  the  United  States  outside  of  Massachusetts,  and  32  cities  and  321 
towns  in  Massachusetts,  have  systems  more  or  less  complete.  New  York  em- 
ploys 150  physicians,  who  visit  each  public  school  once  a  day  to  examine  chil- 
dren set  aside  for  that  purpose  by  the  teacher.  In  Providence  a  fresh-air 
school  for  children  suffering  from  tuberculosis  has  been  established.  The  cost 
of  the  school  per  capita  is  about  50  per  cent  more  than  the  ordinary  schools, 
but  the  results  justify  the  expenditure. 

Our  scholars  are  being  seriously  injured  by  nervous  overstrain.  Probably 
this  is  not  because  too  much  work  is  being  required,  but  because  the  perform- 
ance of  this  work  is  not  accomplished  economically.  Some  experiments  seem 
to  indicate  that  children  could  accomplish  as  much  intellectually  with  far  less 
dissipation  of  nervous  energy  if  they  were  in  the  schoolroom  about  half  of  the 
time  now  spent  there.  High  pressure  and  long  hours  are  bad  economy  in 
schools  as  in  factories. 

Playgrounds  conserve  child  vitality  and  are  far  superior  to  formal  gymnastics. 
They  provide  physical  training  which  accords  with  child  instincts,  and  keep  the 
child  out  of  mischief  and  often  out  of  jail.  Here,  as  elsewhere,  the  suppression 
by  civilized  and  urban  life  of  the  instinct  for  play  and  amusement  is  re- 
sponsible for  much  of  what  we  call  "  crime  "  and  "  depravity."  In  school  children 
should  not  only  be  surrounded  by  hygienic  environment,  but  should  be  taught 
the  value  of  hygiene.  The  suggestion  of  an  annual  "health  day"  or  "health 
week  "  may  prove  a  fruitful  one  for  this  purpose. 

Sec.  5.  Voluntary  and  business  organizations. — Societies  to  prevent  the  spread 
of  tuberculosis,  social  diseases,  insanity,  etc.,  or  to  advocate  labor  or  health 
legislation  (state  and  national),  are  now  numerous  and  active.  It  is  being 
found  that  philanthropy  and  profit  are  not  always  antagonistic.  Labor  organi- 
zations are  connecting  the  health  movement  with  the  eight-hour  movement. 
Farsighted  employers  are  providing  social  secretaries  to  watch  over  the  health, 
comfort,  and  happiness  of  their  employees,  and  are  often  eager  for  practical 
suggestions  in  these  matters. 

Corporations  that  have  installed  apparatus  for  ventilation  and  sanitation, 
even  sometimes  for  the  benefit  of  their  machinery  rather  than  their  employees, 
have  in  known  instances  gotten  back  the  cost  in  lessened  illness  and  greater 
efficiency  of  work. 

An  interesting  experiment  near  Paris  was  that  of  a  mill  employing  44  men 
and  75  women  and  children.  Largely  through  the  services,  instruction,  and 
suggestions  of  a  medical  officer  there  was  not  a  single  death  in  three  years. 

The  temperance  reform  has  to-day  a  powerful  impulse  in  the  demands  by 
employers  for  more  efficient  labor  and  by  the  public  for  greater  safety  in 
travel.  Locomotive  engineers,  conductors,  and  ship  captains  who  drink  can  not 
get  employment. 

Life-insurance  companies  may  possibly  in  the  future  realize  their  opportunity 
to  make  financial  gains  by  participation  in  the  health  movement. 

Finally,  one  of  the  greatest  potential  agencies  for  bringing  about  health  re- 
form is  the  public  press.  It  is  already  interested  and  active  in  the  movement, 
although  the  good  it  does  is  often  undone  by  inserting  quack  advertising.  This 
not  only  does  direct  harm,  but  often  ties  the  hands  of  the  editor,  preventing 
him  from  expressing  any  disapproval  of  nostrums,  however  injurious  or 
immoral. 

SUMMABY  OF  CHAPTER  IX — CONSERVATION  THROUGH  PERSONAL  HYGIENE. 

Section  1.  Its  importance. — Personal  hygiene  is  not  only  of  direct  importance 
to  the  individual,  but  furnishes  the  public  opinion  from  which,  and  from  which 
alone,  sound  public  and  semipublic  hygiene  can  spring.    Public  hygiene  will  be 


REPORT   ON    NATIONAL  VITALITY.  9 

Ineffective  unless  supported  by  personal  hygiene.  The  milk  and  water  supply  of 
a  city  may  be  ideal  as  supplied  at  a  dwelling,  but  may  be  carelessly  contami- 
nated there.  Observation  shows  that  many  of  the  world's  most  vital  men  and 
women  have  practiced  hygiene  and  often  thereby  turned  weak  constitutions 
into  strong  ones.  Cornaro,  the  Venetian  nobleman,  about  to  die  at  37,  adopted 
the  "  temperate  life,"  taking  especial  care  not  to  overeat.  He  lived  to  be  nearly, 
or  quite,  100. 

Sec.  2.  Branches  of  personal  hygiene. — Personal  hygiene  comprises  hygiene 
of  environment  (air,  soil,  dwellings,  clothing),  hygiene  of  nutrition,  and  hygiene 
of  activity.  The  ideal  conditions  of  health  require  purity  in  air,  purity  and 
proper  use  of  food,  and  a  proper  balance  between  mental  and  physical  activity, 
rest,  and  sleep.  The  present  world-wide  interest  in  personal  hygiene  and 
physical  education  is  not  due  to  any  startling  discoveries,  but  to  the  rediscovery 
of  the  importance  of  truths  long  insisted  upon  by  the  medical  profession. 

Sec.  3.  The  hygiene  of  environment. — The  prime  factor  in  environment  is  the 
atmosphere.  Originally  man  was  doubtless  an  outdoor  animal.  Civilization  has 
brought  him  an  indoor  environment,  and  with  it  tuberculosis.  Experiments  in 
hospitals  have  shown  that  the  agitation  of  the  air  by  dry  sweeping  greatly 
increases  bacteria.  Air  in  a  confined  room  may  be  contaminated  by  chemicals 
contained  in  wall  paper,  plaster,  or  mortar.  The  one  place  in  which  the  indi- 
vidual has  most  control  over  his  air  supply  is  the  bedroom.  The  fashion  now  of 
sleeping  with  wide-open  windows,  or  even  out-of-doors,  is  certain  to  improve 
American  vitality.  The  windows  of  living  and  work  rooms  also  may  be  open 
even  in  winter  if  a  window  board  is  used  to  deflect  the  air  upward  and  prevent 
a  cold  stratum  forming  on  the  floor.  The  outdoor  life  or  the  abundant  use  of 
fresh  air  is  an  almost  certain  preventive  of  colds.  This  fact  was  commented 
upon  by  Franklin  over  a  century  ago,  and  has  been  rediscovered  many  times 
since,  especially  in  the  experience  of  army  troops.  The  evils  of  bad  air  are  not 
confined  to  its  chemical  content.  A  room  is  sometimes  "  close  "  simply  because 
it  is  hot  or  overmoist  or  devoid  of  any  air  current. 

The  effect  of  air  on  the  skin  and  of  radiation  of  heat  from  the  body  is  im- 
portant. Consequently,  a  proper  use  of  air  involves  a  proper  use  of  clothing, 
which  needs  to  be  both  porous  and  light. 

Closely  connected  with  air  hygiene  is  the  hygiene  of  light.  "  Where  sun  and 
air  enter  seldom  the  physician  enters  often."  The  lighting  of  dwellings  and 
schoolrooms  is  especially  important  with  reference  to  the  eyes.  This  is  true  also 
of  even  the  color  and  texture  of  the  printed  page  we  read.  Probably  one-fourth 
of  all  educated  people  in  America  suffer  from  disturbances  due  more  or  less  to 
eye  strain  and  its  numerous  indirect  effects. 

Sec.  4.  The  hygiene  of  nutrition. — The  scientific  study  of  diet  has  only  just 
begun,  and  few  authoritative  results  can  yet  be  stated.  That  diet  has  a  dis- 
tinct relation  to  endurance  has  been  rendered  probable  by  many  investigations, 
which  seem  to  show  in  particular  that  avoidance  of  overeating,  and  especially 
of  excess  in  protein,  and  thorough  mastication  are  wholesome  rules.  In  the 
choice  of  foods  the  individual  must  be  given  a  wide  latitude.  His  own  instinct, 
restored  and  educated  by  avoiding  food-bolting  which  blunts  it,  will  probably 
be  a  truer  guide  than  the  wisest  of  physiologists.  Diseased  foods,  such  as 
oysters  polluted  with  sewage,  may  transmit  typhoid  and  other  maladies. 

Sec.  5.  Drug  haMts. — Poisons,  whether  taken  into  the  body  or  produced 
within,  are  injurious.  The  commonest  form  of  intoxication  is  alcoholic.  Its 
evils  are  becoming  more  apparent  than  ever  before.  As  Metchnikoff  says,  it 
lowers  the  resistance  of  the  white  corpuscles,  which  are  the  natural  defenders 
of  the  body.  It  predisposes  to  tuberculosis  and  numerous  other  diseases. 
The  findings  of  the  "  Committee  of  Fifty  "  for  the  investigation  of  the  liquor 
problem  are  important  evidence  of  the  evils  of  the  use  of  alcohol,  and  these 
have  not  received  the  attention  which  they  deserve.  Absinthe  in  France  is 
being  recognized  now  as  a  distinct  menace  to  the  nation,  and  in  Germany 
there  is  a  tendency  toward  a  lessened  use  of  alcohol  in  all  its  forms.  But  the 
movement  against  the  abuse  of  alcohol  has  reached  its  highest  point  in 
America. 

The  evils  of  tobacco  are  less  and  are  less  appreciated.  Its  stunting  effects 
on  the  growing  child  are  especially  harmful. 

Sec  6.  Activity  hygiene. — It  is  an  encouraging  sign  of  the  times  that  baths 
are  coming  more  into  vogue,  both  through  the  private  bath  tub  for  the  wealthy 
and  the  public  baths  for  the  poor.  During  the  last  generation  the  importance 
of  exercise  has  come  to  be  acknowledged,  due  largely  to  the  growth  of  modern 
athletics.     The  athletic  ideal  of  the  Greeks  was,  however,  higher  than  that 


10  REPORT   ON   NATIONAL  VITALITY. 

which  now  prevails  in  this  country.  Overexertion,  physical  and  mental,  is  one 
of  the  chief  American  faults.  The  danger  signal  of  fatigue  is  seldom  observed, 
and  the  instinct  for  recreation  and  amusement  is  often  stifled. 

Sec.  7.  Sex  hygiene. — Undue  reticence  on  this  subject  is  responsible  for  the 
general  ignoi'ance  as  to  the  extent  to  which  the  abuse  of  the  sex  relation  is  in- 
juring this  and  every  nation,  physically,  mentally,  and  morally.  Syphilis 
poisons  the  blood  and  affects  all  parts  of  the  body.  It  makes  the  individual  a 
"  bad  risk  "  for  life  insurance  companies  for  several  years,  and  is  likely  to  be 
transmitted  to  others  through  a  kiss  or  through  the  use  of  a  common  towel, 
while  the  danger  of  transmitting  from  husband  to  wife,  or  vice  versa,  continues 
for  many  years.  Syphilis  is  one  of  the  few  really  hereditary  diseases,  and  the 
saddest  of  all  facts  connected  with  it  is  that  the  guilty  parent  may  escape  and 
the  innocent  children  suffer.  Gonorrhoea,  while  usually  cured  without  ap- 
parent impairment  of  health,  destroys  fertility,  and  for  years  after  it  has  ap- 
parently ceased  may  be  rearoused.  It  is  responsible  for  a  large  number  of 
the  cases  of  infantile  blindness  and  for  a  larger  percentage  of  many  of  the 
serious  troubles  of  women.  The  social  diseases,  while  seldom  assigned  as  a 
cause  of  death,  are  known  to  predispose  to  other  diseases  and  greatly  to 
shorten  life. 

Sec.  8.  Personal  hygiene  in  general. — The  cumulative  effect  of  hygiene,  or  of 
lack  of  hygiene,  needs  emphasis.  Breathing,  eating,  working,  and  sleeping  are 
matters  of  daily  habit.  If  they  are  wrong,  the  evil,  however  slight,  being  re- 
peated every  day  for  many  years,  produces  cumulative  effects  more  subtle,  but 
often  more  powerful,  than  the  effects  of  sudden  infection  or  accident. 

SUMMABY   OF   CHAPTER   X — ARE   HYGIENIC    MEASURES   EUGENIC? 

Section  1.  The  prolongation  of  weak  lives. — The  question  has  been  raised 
whether  reduction  in  infant  and  child  mortality  will  not  weaken  rather  than 
strengthen  the  race  by  interfering  with  natural  selection  and  favoring  the  sur- 
vival of  the  unfit.  It  is  pointed  out  that  the  mortality  at  later  ages  of  life  has 
not  decreased,  as  has  that  in  the  earlier  ages.  There  is  probably,  however,  a 
sufficient  explanation  of  this  in  the  fact  that  the  improvement  in  hygienic  living 
has  not  as  yet  affected  adults  as  much  as  children.  Parents  are  quick  to  apply 
for  the  benefit  of  their  children  new  methods  of  preventing  disease,  such  as 
sterilizing  milk,  but  do  not  take  the  same  precautions  for  themselves.  The 
hurry  and  stress  of  modern  life  has  in  fact  tended  to  produce  in  some  respects 
more  unhygienic  habits  among  adults  than  prevailed  under  the  simpler  condi- 
tions of  a  generation  ago. 

Sec.  2.  Children's  diseases  impair  l)oth  fit  and  unfit. — It  must  be  borne  in  mind 
also  that  the  same  children's  diseases  and  other  causes  which  tend  to  kill  the 
unfit  child  also  tend  to  injure  the  proper  development  of  the  fit.  Consequently 
a  lessening  of  children's  diseases  will  have  the  effect  of  not  only  prolonging 
weak  lives,  but  also  of  prolonging  and  developing  the  strong.  Statistics,  so  far 
as  available,  appear  to  show  that  where  infant  mortality  is  the  highest,  mor- 
tality at  all  ages  is  high. 

Sec.  3.  Fitness  is  relative  to  environment. — What  is  sometimes  called  degen- 
eration does  not  deserve  that  name.  A  lessening  of  physical  strength,  for 
instance,  can  not  be  called  degeneration  if  conditions  under  civilization  do  not 
require  the  same  physical  strength  as  our  barbarian  ancestors  needed.  It  is 
adaptation  to  existing  conditions  which  measures  fitness. 

Whatever  danger  of  degeneration  there  may  be  from  the  care  of  the  Insane 
and  defective  classes  can  be  avoided  if  the  health  ideals  of  the  nation  are  strong 
and  broad  enough  to  meet  the  situation,  for  with  these  high  health  ideals  will 
come  a  demand  which  will  prevent  the  perpetuation  of  the  unfit  and  through 
the  mere  force  of  public  opinion  lead  in  general  to  healthier  marriages. 

Summary  of  Part  IV. — Results  of  conserving  life. 

SUMMARY  OF  CHAPTER  XI — PROLONGATION  OF  LIFE. 

Section  1.  Life  is  lengthening. — So  far  as  we  can  judge  from  statistics  of  the 
average  duration  of  life,  it  has  been  on  the  increase  for  three  hundred  and  fifty 
years,  and  is  now  increasing  more  rapidly  than  ever  before.  During  the  seven- 
teenth and  eighteenth  centuries  the  increase  was  at  the  rate  of  about  four  years 
per  century ;  during  the  first  three-quarters  of  the  nineteenth  century  the  rate 
was  about  nine  years.    At  present  in  Massachusetts  life  is  lengthening  at  the 


REPORT   ON    NATIONAL  VITALITY.  11 

rate  of  about  fourteen  years  per  century ;  in  Europe  about  seventeen ;  and  In 
Prussia,  the  land  of  medical  discovery  and  its  application,  tvv^enty-seven.  In 
India,  where  medical  progress  is  practically  unknown,  the  life  span  is  short 
(twenty-five)  and  remains  stationary. 

Sec.  2.  Table  showing  further  practicahle  prolongation. — It  is  possible  to 
estimate  the  effect  on  the  length  of  life  of  the  partial  elimination  of  various 
diseases.  Using  the  statistics,  experience,  and  estimate  of  18  physicians  as 
to  the  preventability  of  each  of  the  list  of  90  causes  of  death,  we  find  that  the 
length  of  life  could  easily  be  increased  from  forty-five  to  sixty,  an  increase  of 
one-third,  or  fifteen  years.  This  would  result  in  a  permanent  reduction  in 
death  rate  of  about  25  per  cent.  The  principal  reductions  would  be  from  infan- 
tile diarrhea  and  enteritis,  over  60  per  cent  of  which  could  be  prevented,  with 
the  result  of  an  addition  to  the  average  length  of  life  of  2.32  years.  Broncho- 
pneumonia, also  an  infant  disease,  could  be  prevented  to  the  extent  of  50  per 
cent,  whereby  life  would  be  lengthened  by  0.60  year.  Meningitis,  which  is 
usually  fatal  at  the  age  of  two,  could  be  prevented  by  at  least  70  per  cent,  and 
this  prevention  would  lengthen  the  average  life  by  0.60  year.  Eighty-five  per 
cent  of  death  by  typhoid  fever  is  unnecessary,  and  if  avoided  would  lengthen 
life  at  least  0.65  year.  It  would  be  feasible  to  prevent  at  least  75  per  cent  of 
cases  of  tuberculosis  of  the  U^ngs,  and  thereby  to  lengthen  life  by  about  two  years. 
If  the  deaths  from  violence  were  reduced  only  35  per  cent,  human  life  would  be 
increased  by  0.S6  year.  The  prevention  of  45  per  cent  of  cases  of  pneumonia 
would  lengthen  life  by  0.94  year.  These  seven  diseases  alone  could  easily  be 
reduced  by  these  amounts  so  as  to  lengthen  life  by  eight  years.  This  could  be 
done  simply  through  insistence  by  the  public  on  pure  milk,  pure  water,  pure 
air,  and  reasonable  protection  from  accidents. 

Sec.  3.  Diagram  showing  effect  of  prolongation  at  different  ages. — If  we  take 
the  diagram  representing  the  life  table  of  Massachusetts  for  1893-1897,  we  may 
use  it  as  the  basis  for  constructing  an  ideal  curve  to  show  the  effect  of  preven- 
tion if  applied  according  to  the  ratios  of  prevention  given  in  the  preceding 
table.  The  results  agree  substantially  with  those  found  in  the  table  and  show 
that  about  thirteen  or  more  years  could  easily  be  added  to  the  average  duration 
of  life.  The  diagram  also  shows  the  extent  to  which  the  additional  life  would 
fall  in  different  ages.  The  per  cent  of  life  which  would  fall  to  the  ages  between 
17^  and  60,  taken  as  the  working  period,  would  remain  the  same,  namely,  about 
55  per  cent. 

Sec.  4.  Fifteen  years  a  safe  minimum  estimate  of  prolongation  possible. — 
The  estimate  of  fifteen  years  is  a  minimum  because,  first.  It  takes  no  account 
of  future  medical  discoveries,  such  as  a  method  of  curing  or  preventing  cancer 
and  of  postponing  old  age,  as  would  Metchnikoff ;  second,  it  takes  little  account 
of  the  cumulative  influence  of  hygiene.  The  full  benefit  of  hygiene  can  not  be 
felt  until  it  is  practiced  throughout  life,  and  not  at  the  approach  of  specific 
danger.  Most  so-called  "  causes  "  of  death  are  merely  the  last  straws  which  break 
the  camel's  back.  When  a  pure  water  supply  prevents  deaths  from  typhoid 
fever,  it  prevents  two  or  three  times  as  many  deaths  from  other  causes.  Third, 
it  takes  no  account  of  the  racial  effects  of  new  health  ideals  leading,  in  a  generaJ 
way,  as  they  must,  to  healthier  marriages. 

Sec.  5.  Need  of  lengthening  human  life. — With  increase  of  knowledge  the 
period  of  education  or  preparation  for  life  must  constantly  increase.  This  fact 
creates  a  need  for  a  longer  life,  with  the  later  periods  of  life  increased  in  pro- 
portion. The  result  of  such  a  prolongation  will  be  not  the  keeping  alive  of 
invalids,  but  the  creation  of  a  population  containing  a  large  number  of  vigorous 
old  men.  Metchnikoff  says,  "  The  old  man  will  no  longer  be  subject  to  loss 
of  memory  or  to  intellectual  weakness;  he  will  be  able  to  apply  his  great 
experience  to  the  most  complicated  and  most  delicate  parts  of  the  social  life." 

Sec.  6.  The  normal  lifetime. — It  is  usually  recognized  that  human  life  is 
abnormally  short,  but  no  exact  determination  has  ever  been  made  of  what 
constitutes  a  normal  lifetime.  Floureus  maintains  that  a  mammal  lives  five 
times  the  length  of  its  growing  period,  which  would  mean,  since  the  growing 
period  for  man  does  not  cease  until  about  30,  a  normal  human  lifetime  of 
one  hundred  and  fifty  years.  Another  method  of  estimating  normal  life  is  to 
reckon  the  length  of  normal  life  as  the  time  when  old  age  now  sets  in,  83  years. 
But  clearly,  if  Metchnikoff  is  right  in  thinking  that  old  age  itself  is  abnormal, 
the  normal  lifetime  must  exceed  83.  Many  remarkable  cases  of  longevity  are 
on  record,  but  most  cases  of  reputed  centenarians  are  not  authenticated. 
Drakenburg's  record  was  authentic,  and  he  lived  to  be  146.     Mrs.  Wood,  of 


12  REPORT   ON   NATIONAL  VITALITY. 

Portland,  Oreg.,  recently  died  at  120.    To  what  extent  these  exceptional  cases 
could  be  made  common  can  not,  as  yet,  be  known, 

SUMMARY   OF    CHAPTES   XII — THE    MONEY    VALUE   OF    INCREASED    VITALITY. 

Section  1.  Money  appraisal  of  preventable  wastes. — Doctor  Farr  has  esti- 
mated the  net  economic  value  of  an  English  agricultural  laborer  at  various  times 
of  life  by  discounting  his  chance  of  future  earnings  after  subtracting  the  cost 
of  maintenance.  On  the  basis  of  this  table  we  may  construct  a  rough  estimate 
of  the  worth  of  an  average  American  life  at  various  ages,  assuming  that  only 
three-fourths  of  those  of  working  age  are  actually  earners  of  money  or  house- 
keepers. It  gradually  rises  from  a  value  of  $90  in  the  first  year  to  $4,200  at 
the  age  of  30,  and  then  declines  until  it  becomes  negative  for  the  higher  ages. 
This  estimate  assumes  $700  per  year  as  the  average  earnings  in  middle  life. 
This  is  largely  conjecture,  but  is  regarded  as  a  very  safe  estimate.  Applying 
this  table  to  the  existing  population  at  various  ages  in  the  United  States,  we 
find  that  the  average  value  of  a  person  now  living  in  the  United  States  is 
$2,900,  and  the  average  value  of  the  lives  now  sacrified  by  preventable  deaths 
is  $1,700.  The  latter  is  smaller  than  the  former  because  the  age  of  the  dying 
is  greater  than  the  age  of  the  living.  Applying  the  $2,900  to  the  population  of 
eighty-five  and  a  half  millions,  we  find  that  our  population  may  be  valued  as 
assets  at  more  than  $250,000,000,000;  and  since  the  number  of  preventable 
deaths  is  estimated  at  630,000,  the  annual  waste  from  preventable  deaths  is 
630,000  times  $1,700,  or  about  $1,000,000,000.  This  represents  the  annual  pre- 
ventable loss  of  potential  earnings. 

We  saw  in  Chapter  III  that  there  are  always  3,000,000  persons  in  the  United 
States  on  the  sick  list,  of  whom  about  1,000,000  are  in  the  working  period  of 
life  and  about  three-quarters  are  actually  workers  and  must  lose  at  least  $700, 
which  makes  the  aggregate  loss  from  illness  more  than  $500,000,000.  Adding 
to  this  another  $500,000,000  as  the  expense  of  medicines,  medical  attendance, 
special  foods,  etc.,  we  find  the  total  cost  of  illness  to  be  about  $1,000,000,000 
per  year,  of  which  it  is  assumed  that  at  least  one-half  is  preventable.  Adding 
the  preventable  loss  from  death,  $1,000,000,000,  to  the  preventable  loss  from 
illness,  $500,000,000,  we  find  one  and  a  half  billions  as  the  very  lowest  at  which 
we  can  estimate  the  preventable  loss  from  disease  and  death  in  this  country. 
The  true  figures  from  the  statistics  available  may  well  amount  to  several  times 
this  figure,  but  when  statistics  are  based  partially  on  conjecture,  they  need  to 
be  stated  with  special  caution. 

Sec.  2.  The  cost  of  conservation. — In  Huddersfield  the  annual  deaths  of  in- 
fants for  ten  years  had  been  310.  By  systematic  education  of  mothers,  the 
number  in  1907  was  reduced  to  212.  The  cost  of  saving  these  98  lives  was 
about  $2,000,  or  about  $20  each.  Gen.  Leonard  Wood  declared  that  the  discovery 
of  the  means  of  preventing  yellow  fever  saves  annually  more  lives  than  were 
lost  in  the  Cuban  war.  The  hook-worm  disease  in  the  South  impairs  the 
earning  power  of  its  workmen  by  25  or  50  per  cent.  To  restore  this  earning 
power  costs,  by  curing  this  disease,  on  an  average,  less  than  $1  for  each  case. 
These  and  other  examples  show  that  the  return  on  investments  in  health  are 
often  several  thousand  per  cent  per  annum.  Probably  no  such  unexploited  op- 
portunity for  rich  returns  exists  in  any  other  field  of  investment.  An  actuary 
suggests  that  if  insurance  companies  should  combine  to  contribute  $200,000  a 
year  for  the  purpose  of  improving  the  public  health,  the  cost  would  be  one- 
eighth  of  1  per  cent  of  the  pi-emiums,  and  it  would  be  reasonable  to  expect  a 
decrease  in  death  claims  of  much  more  than  1  per  cent.  Even  this  1  per  cent 
would  make  a  profit  of  more  than  seven  times  the  expense. 

SUMMARY  OF  CHAPTER  XIII — THE  GENERAL  VALUE  OF  INCREASED  VITALITY. 

Section  1. — Disease,  poverty,  and  crime. — Money  estimates  of  waste  of  life 
are  necessarily  imperfect  and  sometimes  misleading.  The  real  wastes  can  only 
be  expressed  in  terms  of  human  misery.  Poverty  and  disease  are  twin  evils 
and  each  plays  into  the  hands  of  the  other.  From  each  springs  vice  and  crime. 
Again,  whatever  diminishes  poverty  tends  to  improve  health,  and  vice  versa. 

Sec.  2.  Conservation  of  natural  resources. — The  conservation  of  our  natural 
resources — land,  raw  materials,  forests,  and  water — will  provide  the  food, 
clothing,  shelter,  and  other  means  of  maintaining  healthy  life,  while  the  con- 
servation  of  health  likewise  tends  in  many  ways  to  conserve  and  increase 


KEPORT   ON    NATIONAL  VITALITY.  13 

wealth.  The  more  vigorous  and  long-lived  the  race,  the  better  utilization  it  will 
make  of  its  natural  resources.  This  will  be  true  for  two  reasons  in  particular : 
First,  the  greater  inventiveness  or  resourcefulness  of  vigorous  minds  in  vigorous 
bodies.  Civilization  consists  chiefly  in  invention  and  the  most  progressive  nations 
are  those  whose  rate  of  invention  is  most  rapid.  Second,  the  greater  foresight 
and  solicitude  for  the  future.  As  it  is  usually  the  normal  healthy  man  who 
provides  life  insurance  for  his  family,  so  it  will  be  the  normal  healthy  nation 
whch  will  take  due  care  of  its  resources  for  the  benefit  of  generations  yet 
unborn. 

SUMMABY  OF  CHAPTEB  XIV — THINGS  WHICH  NEED  TO  BE  DONE. 

Section  1.  Enumeration  of  principal  measures. — Federal,  state,  and  municipal 
boards  of  health  should  be  better  appreciated  and  supported.  Their  powers  of 
investigation,  administration,  and  disseminating  information  should  be  en- 
larged. School  hygiene  should  be  practiced,  and  personal  hygiene  more  empha- 
sized.   The  multiplication  of  degenerates  should  be  made  impossible. 


INTRODUCTION. 

At  the  conclusion  of  his  White  House  address  on  the  "  Conserva- 
tion of  Natural  Eesources,"  President  Roosevelt  said: 

Finally,  let  us  remember  that  the  conservation  of  our  natural  resources, 
though  the  gravest  problem  of  to-day,  is  yet  but  part  of  another  and  greater 
problem  to  which  this  nation  is  not  yet  awake,  but  to  which  it  will  awake  in 
time,  and  with  which  it  must  hereafter  grapple  if  it  is  to  live — the  problem  of 
national  efficiency. 

The  conditions  on  which  national  efficiency  depend  may  be  classi- 
fied under  three  heads:  Those  relating  to  physical  environment, 
those  relating  to  social  environment,  and  those  relating  to  human 
nature.  Under  the  first  head  comes  the  problem  of  the  conservation  of 
land,  forests,  minerals,  and  water.  The  second  comprises  social  ques- 
tions, whether  political,  economic,  or  religious.  The  third  covers 
the  study  of  the  characteristics  of  man  himself — physical,  mental,  and 
moral. 

This  report  falls  under  the  third  head,  concerning  as  it  does  vital- 
ity, the  measure  of  life  itself,  and  the  basis  of  all  human  qualities. 
The  object  is  to  review  briefly  the  condition  of  American  vitality, 
contrasted  with  the  vitality  of  other  nations;  to  show  the  extent  to 
which  it  may  be  increased;  and  to  point  out  the  value  of  such  an 
increase  in  years  of  life,  enjoyment  of  life,  and  economic  earnings. 

The  world  is  gradually  awakening  to  the  fact  of  its  own  improvabil- 
ity.  Political  economy  is  no  longer  the  "dismal  science,"  teaching 
that  starvation  wages  are  inevitable  from  the  Malthusian  growth 
of  population,  but  is  now  seriously  and  hopefully  grappling  with 
the  problem  of  abolition  of  poverty.  In  like  manner  hygiene,  the 
youngest  of  the  biological  studies,  has  repudiated  the  outworn  doc- 
trine that  mortality  is  fatality,  and  must  exact  a  regular  and  in- 
evitable sacrifice  at  its  present  rate  year  after  year.  Instead  of  this 
fatalistic  creed  we  now  have  the  assurance  of  Pasteur  that  "  It  is 
within  the  power  of  man  to  rid  himself  of  every  parasitic  disease," 
as  well  as  the  optimistic  writings  of  Metchnikoff  and  others. 

Many  evidences  of  a  world-wide  awakening  to  the  importance  of 
improving  human  vitality  can  be  given.  Among  them  are  the  recent 
English  parliamentary  report  of  the  interdepartmental  committee 
on  physical  degeneration  (prompted  by  the  fact  that  the  English 
army  recruits  Avere  decreasing  in  stature)  ;  in  America,  the  many 
societies  and  congresses  to  prevent  and  control  tuberculosis,  insanity, 
alcoholism,  social  diseases  and  vice,  and  infant  mortality ;  the  growth 
of  preventive  sanatoria,  dispensaries,  and  similar  institutions;  the 
establishment  of  numerous  journals  of  preventive  medicine,  both 
technical  and  popular;  the  increased  attention  to  the  subject  of 
health  in  the  public  press;  the  spread  of  athletics  and  the  physical 
training  movement;  the  growth  of  the  custom  among  city  people  to 

14 


KEPORT   ON   NATIONAL  VITALITY.  15 

organize  country  clubs,  and  the  increasing  popularity  of  golf  and 
similar  recreations;  the  constant  agitation  and  legislation  in  refer- 
ence to  child  labor,  slaughterhouses,  impure  foods,  milk  supply,  and 
water  contamination;  the  increased  vigilance  of  health  boards;  the 
growth  of  sick-benefit  associations  and  insurance  among  working 
men;  the  efforts  toward  improving  the  sanitary  surroundings  and 
hours  of  labor  of  workmen,  and  especially  of  women  and  children, 
and,  finally,  the  movement  to  secure  a  national  organization  of  health 
at  Washington. 

A  number  of  universities  are  supporting  special  investigations  in 
physiology,  hygiene,  and  preventive  medicine.  Some  schools  also 
have  placed  the  allied  subjects  of  domestic  science  and  dietetics  on 
their  curricula,  while  physical  education  is  receiving  constantly  in- 
creasing attention.  Within  a  generation  every  important  college, 
school,  and  branch  of  the  Young  Men's  Christian  Association  has 
come  to  have  a  gymnasium  and  classes  in  gymnastics.  Research  insti- 
tutions are  being  established,  such  as  the  Rockefeller  Institute  for 
Medical  Research,  the  fund  established  by  Mrs.  Sage  to  study  dis- 
eases of  old  age,  and  the  Memorial  Institute  for  Infectious  Diseases. 
The  home-economics  movement  is  rapidly  growing  and  seems  destined 
to  improve  greatly  the  management  of  American  homes. 

The  practice  of  medicine,  which  for  ages  has  been  known  as  the 
"healing  art,"  is  undergoing  a  gradual  but  radical  revolution.  The 
change  is  based  on  the  conviction  that  an  ounce  of  prevention  is 
worth  a  pound  of  cure.  As  teachers  and  writers  on  hygiene,  as 
trainers  for  athletes,  as  advisers  for  the  welfare  departments  of  large 
industrial  plants,  and  in  many  other  directions,  physicians  are  find- 
ing fields  for  practicing  preventive  medicine.  There  is  a  still  higher 
stage  of  medical  science  than  that  of  fighting  or  preventing  disease 
in  the  individual — the  stage  which  has  been  called  "biological  engi- 
neering," i.  e.,  the  study  of  the  conditions  under  which  the  individual 
may  reach  his  highest  efficiency.  In  the  development  of  this  science 
physicians  are  turning  from  private  practice  to  public  service  and 
are  acting  as  health  officers  in  federal,  state,  and  city  governments, 
as  heads  of  sanatoria  and  as  medical  inspectors  of  schools,  factories, 
mines,  and  shops.  Even  the  family  physician  is  in  some  cases  being 
asked  by  his  patients  to  keep  them  well  instead  of  curing  them  after 
they  have  fallen  sick. 

Finally,  we  have  also  the  suggestion  by  Sir  Francis  Galton  of  the 
new  science  of  eugenics,  which  seeks  to  study  the  hereditary  condi- 
tions of  human  vitality.  He  has  established  a  research  fellowship 
on  the  subject  at  the  University  of  London.  Already  Karl  Pearson 
and  others  have  made  valuable  contributions  to  the  study  of  human 
degeneration,  the  effect  of  tuberculosis  on  the  race,  the  comparative 
number  of  offspring  of  various  classes,  and  the  extent  to  which 
mating  is  "  assortative,"  so  that  like  marries  like. 

With  all  these  facts  in  view  it  requires  no  great  prophetic  vision 
to  see  that  among  the  rising  generation  there  will  be  a  great  move- 
ment to  conserve  human  life  and  health.  The  power  and  success  of 
this  movement  will  depend  upon  the  realization  of  its  stupendous 
importance.  A  chief  object  of  this  report  is,  in  a  conservative  and 
cautious  manner,  to  help  make  this  importance  clear. 


Part  I.— THE  LENGTH  OF  LIFE  VERSUS  MORTALITY. 

Chapter  I. — The  length  of  life. 

Section  1. — In  different  places. 

By  those  who  have  never  considered  the  problem,  death  and  disease 
are  accepted  as  a  matter  of  course.  In  individual  cases  it  is  recog- 
nized that  a  death  or  an  illness  might  have  been  prevented,  but  the 
idea  that  the  death  rate  could  be  changed  in  any  appreciable  degree, 
or  controlled,  is  quite  foreign  to  the  mind  of  the  average  man. 
Charles  Babbage  wrote :  "  There  are  few  things  less  subject  to  fluctua- 
tion than  the  average  duration  of  life  of  a  multitude  of  individuals."  * 

If  this  statement  were  correct,  we  should  find  the  average  duration 
of  life  ^  and  the  death  rate  substantially  the  same  in  different  places 
and  at  different  times.  The  facts  do  not  conform  to  this  view. 
Modern  life  tables  show  that  the  average  length  of  life  in  the  leading 
countries  of  the  world  varies  remarkably,  as  the  following  figures 
will  illustrate." 

Modem  duration  of  life. 


Country. 


Females. 


Sweden,  1891-1900 

Denmark,  1895-1900 

France,  1898-1903 

England  and  Wales,  1891-1900 

United  States  (Massachusetts,  1893-1897) o 

Italy,  1899-1902 

Prussia,  1891-1900 

India,  19016 


53.6 
53.2 
49.1 
47.7 
46.6 
43.1 
445 
24.0 


"  Samuel  W.  Abbott,  M.  D.  :  "  Vital  Statistics  of  Massachusetts  for  1897,"  Thirtieth 
Annual  Report  of  the  State  Board  of  Health  of  Massachusetts,  1898. 

*  Statistiques  Generale  de  la  Prance :  Statistiques  Internationales,  etc.,  1907,  p.  566. 
See  also  J.  A.  Baines,  "  The  Peradventures  of  an  Indian  Life  Table,"  Journal  Royal  Sta- 
tistical Society,  1908,  Vol.  LXXI,  part  2,  p.  310,  where  the  average  duration  of  life  for 
males  is  given  as  23.6. 

When  we  consider  that  the  average  duration  of  life  in  India  is 
scarcely  more  than  one-half  that  of  France  and  less  than  one-half 

»  Charles  Babbage :  "A  Comparative  View  of  the  Various  Institutions  for  the 
Assurance  of  Lives,"  p.  15.    London,  1826. 

*  By  average  duration  of  life  or  the  life  span  is  meant  the  average  length  of 
life  among  a  large  number  of  persons  born  taken  at  random.  It  is  not  the  same 
as  the  average  age  at  death  in  a  community  during  a  year,  since  that  com- 
munity may  contain  an  abnormally  large  proportion  of  infants,  or  of  any  other 
"age  group." 

c  Some  of  the  figures,  especially  those  for  India,  rest  on  imperfect  data,  but 
they  are  believed  to  be  sufficiently  accurate  for  general  comparison. 

16 


KEPORT   ON   NATIONAL  VITALITY.  17 

that  of  Sweden,  we  must  conclude  that  the  length  of  human  life  is 
dependent  on  definite  conditions  and  can  be  increased  or  diminished 
by  a  modification  of  those  conditions. 

Section  2. — At  different  times. 

Striking  corroboration  of  this  conclusion  is  found  as  soon  as  we 
compare  the  average  duration  of  life  at  different  periods  of  time. 
The  earliest  attempt  to  discover  a  law  of  human  mortality  appears  to 
be  that  of  Ulpian,  a  Roman  pretorian  prefect,  about  220  A.  D.  The 
meaning  of  his  table  is  somewhat  doubtful,  but  it  is  assumed  to  refer 
to  "  expectation  of  life,"  which  for  ages  up  to  20  is  given  as  thirty 
years." 

This  estimate  is  so  crude  and  vague  as  to  be  of  little  value  for 
comparative  purposes.  Professor  Finkelnburg,  of  Bonn,  estimates 
that— 

The  average  lengtli  of  human  life  in  the  sixteenth  century  was  only  between 
eighteen  and  twenty  years,  and  that  at  the  close  of  the  eighteenth  century  it 
was  a  little  over  thirty  years,  while  to-day  it  is  between  thirty-eight  and  forty 
years.^ 

In  Geneva  the  records  go  back  over  three  centuries  showing  the  fol- 
lowing life  span : " 

16th   century 21.2 

17th   century 25.7 

18th   century L 33.6 

1801-1883 39.7 

Here  we  see  an  increase  in  the  span  of  life  of  100  per  cent  in  three 
or  four  centuries.  The  last  few  decades,  moreover,  tell  a  striking  story 
of  increase.  It  is  one  of  the  boasts  of  the  nineteenth  century  that  the 
splendid  medical  and  scientific  advances  of  that  period  have  aided  in 
a  distinct  lengthening  of  life. 

In  1693  the  British  Government  borrowed  money  by  selling  an- 
nuities, and  in  1790,  a  century  later,  it  did  the  same  thing.  While 
the  first  venture  proved  satisfactory,  the  second  caused  a  great  loss  to 
the  Government,  owing  to  the  improvement  in  longevity  which  had 
taken  place,  and  which  was  estimated,  for  the  annuitant  class,  at 
20  years.*^ 

If  we  compare  Ogle's  English  life  tables  for  1871-1881  with  those 
of  Farr  for  1838-1854,  we  find  an  increase  in  life  span  of  1.4  years 
for  males  and  2.8  for  females.^ 

<^  See  Irving  Fisher :  "  Mortality  Statistics  of  the  United  States  Census,"  pub- 
lications of  the  American  Economic  Association,  Monograph  on  Federal  Census, 
1899,  p.  157.    Taken  from  Assurance  Magazine,  VI,  p.  314 ;  note. 

^  George  M.  Kober,  M.  D. :  "  Conservation  of  Life  and  Health  by  Improved 
Water  Supply,"  publications  of  conference  on  the  conservation  of  natural  re- 
sources, 1908,  p.  23.  Washington,  D.  C,  privately  published.  From  Finkeln- 
burg's  "  Organisation  der  offentl.  Gesundheitsphlage  in  der  Kulturstaaten  "  in 
Handbuch  der  Hygiene,  1893. 

f'  From  Mallet  in  "Annales  d'  Hygiene,"  XVII,  169 ;  quoted  by  Dr.  Edward 
Jarvis,  "  Political  Economy  of  Health,"  in  Fifth  Annual  Report,  Mass.  Board  of 
Health,  1874. 

^  See  Dr.  Southward  Smith,  Transactions  British  Social  Science  Association, 
1857,  p.  498,  quoted  by  Dr.  Edward  Jarvis,  ibid. 

®  R.  Mayo-Smith :  "  Statistics  and  Sociology,"  p.  178.  New  York  (Macmillan)  • 
1895. 


18  EEPORT   ON   NATIONAL  VITALITY. 

A  still  greater  improvement  has  been  effected  since  Ogle's  figures 
of  1871-1881 : 

Lifetime  in  England  and  Wales: 
Males — 

1838-1854 39.  9 

1891-1900 44. 1 

Females — 

1838-1854 41.  8 

1891-1900 47.8 

Similar  improvements  are  observable  in  other  countries. 

Lifetime  in  France: 

Males — 

1817-1831 38.  3 

1898-1903 45.  7 

Females — 

1817-1831 40. 8 

1898-1903 49. 1 

Lifetime  in  Prussia : 

Males — 

1867-1877 35.  3 

1891-1900 41. 1 

Females — 

1867-1877 37.  9 

1891-1900 44.  6 

Lifetime  in  Denmark : 

Males — 

1835-1844 42.  6 

1895-1900 50.  2 

Females — 

1835-1844 44.  7 

1895-1900 53.  2 

Lifetime  in  Sweden : 

Males — 

1816-1840 39.  5 

1891-1900 50.  9 

Females — 

1816-1840 .  43.  5 

1891-1900 53.6 

It  is  difficult  to  obtain  American  life  tables  that  go  far  enough  back 
into  history  to  display  increases  in  the  life  span  similar  to  those  just 
presented ;  yet  comparisons  of  Abbott's  Massachusetts  life  tables  for 
1893-1897  with  Elliott's  Massachusetts  tables  for  1855  and  Wiggles- 
worth's  Massachusetts  and  New  Hampshire  life  tables  of  a  century 
ago  give  us  a  progressive  increase  from  35  in  1789  "•  to  40  in  1855  ^ 
and  45  in  1893-1897."  Unfortunately  no  tables  exist  for  the  United 
States  as  a  whole  from  which  similar  comparisons  might  be  made. 
Good  and  reliable  vital  statistics  are  among  our  most  crying  needs. 
Meech's  life  tables,  based  on  the  census  figures  of  1830,  1840,  1850, 
and  1860,  showed  a  life  span  for  the  whole  country  of  42.<^ 

oE.  Wigglesworth :  "Table  showing  the  probability  of  the  duration,  the 
decrement  and  the  expectation  of  life  in  the  States  of  Massachusetts  and  New 
Hampshire,  formed  from  62  bills  of  mortality  on  the  files  of  the  American 
Academy  of  Arts  and  .Sciences  in  the  year  1789."  Memoir  of  the  American 
Academy  of  Arts  and  Sciences,  Vol.  II,  p.  133. 

^  Proceedings  American  Association  for  the  Advancement  of  Science,  1857, 
pp.  61  and  69. 

"Abbott,  loc.  cit. 

^  Levi  W.  ]\Ieeeh :  "  Ss^stem  and  Tables  of  Life  Insurance,"  ed.  of  1886,  pp. 
255-259.  The  figures  for  life  span  at  different  periods  given  in  this  paragraph 
have  been  secured  by  averaging  the  figures  for  males  and  females. 


EEPOKT   ON   NATIONAL,  VITALITY.  19 

The  census  of  1880  gave  some  70  sets  of  life  tables  for  different 
registration  States  and  cities.  The  expectation  of  life  for  white 
males  was  given  for  Massachusetts  as  44,  New  Jersey  46,  District  of 
Columbia  41,  and  New  York  City  33,  but  in  constructing  the  tables 
"  the  census  was  too  prodigal  as  to  quantity  and  somewhat  careless  as 
to  quality.  It  is  difficult  to  separate  the  wheat  from  the  chaff.  The 
table  should  have  been  accompanied  by  a  running  criticism.  The 
general  defect  was  that  no  attempt  was  made  to  correct  the  deficiencies 
in  the  returns  for  infants."  °'  The  census  for  1890  gives  only  a  few 
life  tables,  and  that  for  1900  none. 

In  striking  contrast  to  these  recent  increases  of  the  life  span  in 
progressive  countries  is  the  table  for  backward  India,  which  showed 
no  advance  in  twenty  years.* 

Lifetime  in  India : 
Males — 

1881 23.7 

1901 23.6 

Chapter  II. — The  mortality  rate. 
Section  1. — Relation   of  longevity   and  mortality. 

The  average  duration  of  life  and  the  death  rate  °  are  two  comple- 
mentary magnitudes.  An  increase  in  the  life  span  means  a  decrease 
in  the  death  rate,  and  vice  versa;  in  fact,  in  a  "stationary"  popula- 
tion (a  population  in  which  the  annual  number  of  deaths  equals  the 
annual  number  of  births,  and  without  emigration  or  immigration), 
it  will  be  true  that  the  average  duration  of  life  and  the  death  rate 
are  mathematically  the  "  reciprocals  "  of  each  other.*^  Thus,  if  the 
death  rate  is  20  deaths  per  annum  for  each  1,000  of  population  (i.  e., 
twenty  one-thousandths  per  annum),  the  average  duration  of  life 
would  be  ^ff "-  =  50  years. 

If  this  reciprocal  relation  between  duration  of  life  and  mortality 
held  true  in  every  population,  it  would  be  easy  to  translate  death 
rates  into  average  duration  of  life,  and  conversely ;  but  unfortunately 
such  a  simple  calculation  is  impracticable  under  conditions  existing 
in  America,  and  even  in  most  countries  of  Europe.  With  the  ex- 
ception of  France,  few  countries  have  even  approximately  an  equality 
between  deaths  and  births  and  an  absence  of  emigration  and  im- 
migration. In  America,  where  the  deaths  are  exceeded  by  the  births, 
and  where  there  is  a  large  immigration  of  young  men  and  women  in 
the  prime  of  life,  the  death  rate  is  smaller  than  it  would  be  if  our 
population  were  "  stationary."    The  annual  death  rate  in  the  United 

«  Fisher :  "  Mortality  Statistics  of  the  United  States  Census,"  American  Eco- 
nomic Association  Monograph  on  the  Federal  Census,  1899,  p.  160. 

*  Baines :  "  The  Peradventures  of  an  Indian  Life  Table,"  Journal  of  the 
Royal  Statistical  Society,  1908,  Vol.  LXXL,  pt.  2,  p.  310. 

"A  death  rate  is  the  ratio  of  the  number  of  deaths  during  a  year  to  the  popu- 
lation, taken  at  some  point  in  the  year,  usually  the  middle. 

^  For  a  short  explanation  of  this  reciprocal  relation,  which  is  more  fully 
explained  in  works  on  actuarial  science,  see  Fisher :  Mortality  Statistics  of  the 
United  States  Census,  pp.  149-150.  It  is  interesting  to  see  the  graphic  in- 
terpretation of  this  reciprocal  relation  by  means  of  the  diagram  in  Chapter 
XI  of  this  Report. 


20  EEPOET   ON   NATIONAL  VITALITY. 

States  is  probably  about  18  per  thousand**  of  population.  The 
reciprocal  of  this  would  be  l,000-^-18,  or  55  years,  which  is  altogether 
too  high  an  estimate  for  the  average  length  or  life  in  the  United 
States. 

It  is  possible  to  "  correct "  the  death  rate  for  "  age  distribution  "  so 
that  its  reciprocal  will  be  the  true  average  duration  of  life,  but  the 
calculation  is  a  difficult  and  tedious  one.  We  are  forced,  therefore, 
to  get  along  in  most  cases  with  the  "  crude  death  rate,"  or  the  quo- 
tient of  the  number  of  deaths  in  a  year  divided  by  the  population. 
This  figure  is  much  easier  to  obtain  than  a  corrected  death  rate  or  its 
reciprocal,  the  average  duration  of  life. 

Our  data  for  death  rates  are  far  more  voluminous  than  our  data 
for  the  average  duration  of  life.  Although  theoretically  death  rates 
are  not  an  unerring  indication  of  longevity,  they  furnish  in  practice 
very  valuable  information.  In  a  general  way  death  rates  may  be 
compared  with  each  other,  especially  in  the  same  community.  For 
instance,  a  decrease  in  the  death  rate  in  New  York  City  from  one  year 
to  another  is  practically  a  certain  indication  of  improvement  in  vital 
conditions. 

Section  2. — Mortality  in  various  regions. 

Forty  years  ago  the  variations  in  the  death  rates  of  the  different 
sections  of  Europe  were  given  by  Quetelet  ^  as  follows : 

Death  rate  per  1,000  population. 

Northern    Europe 24.  3 

Central  Europe 24,  5 

Southern    Europe 29. 7 

To-day  the  death  rates  of  various  countries  compare  with  each 
other  as  in  the  following  table : 

Modern  death  rates  per  1,000  of  population." 

Denmark  (1906) 13.  5 

Sweden    (1906) 14. 4 

England  and  Wales    (1906) 15.4 

United  States    (registration  area)    (1907) 16.5 

Germany   (1905) 19.  8 

France    (1906) 19.  9 

Italy    (1906) 20.  8 

Japan    (1905) 21.9 

India  (males,^  1901) 42.3 

As  we  found  in  the  study  of  duration  of  life,  so  we  find  here  wide 
variations  from  country  to  country.  Italy  presents  a  death  rate 
larger  by  nearly  one-sixth  than  that  of  the  United  States,  while 
famine-tortured  and  plague-ridden  India's  mortality  rate  is  twice 
that  of  France  and  three  times  the  rates  of  Denmark  and  of  Sweden. 

o  W.  F.  Willcox :  "  Death  Rate  of  the  United  States  in  1900,"  publications 
of  the  American  Statistical  Association,  Vol.  X,  p.  155. 

&  Quetelet,  Physique  Sociale,  Vol.  I,  p.  281.  These  figures  refer  to  the  ex- 
perience of  different  periods  between  1801  and  1831. 

c  With  the  exception  of  the  figures  for  India,  this  table  is  taken  from  figures 
furnished  by  the  Bureau  of  the  Census. 

<^Baines,  loc.  cit,  p.  310. 


REPORT   ON    NATIONAL  VITALITY.  21 

Even  the  fairly  homogeneous  population  of  our  registration  States 
in  America  shows  variations  in  death  rates." 

Death  rate  per  1,000  population  in  1900. 

Michigan 13.  9 

Vermont 17.  0 

Massachusetts 17.  7 

New  York 17.  9 

The  death  rate  in  Michigan,  at  the  one  extreme,  is  thus  but  three- 
fourths  that  of  New  York  at  the  other  extreme.  This  difference  may 
probably  be  accounted  for  in  part  by  the  difference  in  the  age  con- 
stitution, as  the  population  for  Michigan  contains  a  larger  propor- 
tion of  population  in  young  and  vigorous  life  than  does  New  York. 

Section  3. — Urban  and  rural  mortality. 

Comparison  of  urban  and  rural  death  rates  also  gives  us  varia- 
tions.^ 

Death  rates  per  1,000  population  in  1900. 

Massachusetts : 

Urban 17.9 

Rural 17. 1 

Michigan : 

Urban 15.3 

Rural 13.  3 

New  Jersey : 

Urban 18.  8 

Rural 15.  5 

Interesting  comparisons  may  be  made  of  the  death  rates  of  Ameri- 
can cities  varying  in  size  and  location.  The  death  rate  per  1,000  of 
population  in  1906  was  given  ^  as  14.2  (probably  incorrect)  in  Chicago, 
m  Boston  18.9,  in  New  York  18.6,  and  in  Philadelphia  19.3.  Cleve- 
land, Ohio,  was  credited  with  a  death  rate  of  but  16,  while  Cincinnati, 
in  the  same  State,  had  20.8.  The  causes  of  such  differences  are  not 
always  attributable  to  variations  in  size.  New  Haven,  for  instance, 
a  larger  Connecticut  city  than  either  Hartford  or  New  London,  had  a 
lower  death  rate  in  1900  by  2.2  and  2.5,  respectively,  per  1,000  popu- 
lation. The  differences  are  accounted  for  partly  by  differences  in 
age  constitution,  partly — it  is  unfortunately  true — by  differences  in 
the  accuracy  of  the  collected  statistics,  partly  by  differences  in  size 
and  location,  and  partly  by  differences  in  the  vigilance  of  the  public 
and  private  health  authorities. 

European  cities  show  even  greater  variations  in  mortality  than 
these  just  given  for  the  United  States. 

o  Twelfth  Census  of  the  United  States,  Vol.  Ill,  p.  LVIIL 

6  United  States  Census  Bulletin,  No.  83,  1901. 

"  Seventh  Annual  Census  Report  on  Mortality  Statistics,  1906. 


22  REPORT  ON   NATIONAL  VITALITY. 

Death  rates  of  European  cities  per  1,000  population,  1897.'* 


Locality. 


Dublin 

Moscow 

Belfast 

St.  Petersbiirg 


High. 


39.9 
36.9 
31.3 
31 


Locality. 


FranMort  on  the  Mata 

The  Hague 

BerllQ 

Amsterdam 


Low. 


15.6 
16.2 
17 
17.8 


« One  must  doubt,  however,  the  accuracy  of  some  of  these  figures,  especially  the 
Russian.  The  rates  in  Moscow  and  St.  Petersburg  in  1906  are  reported  as  25.8  and  25.5, 
respectively,  which  do  not  comport  with  the  rates  for  1897. 

Section  4. — Race  and  condition. 

The  variations  in  death  rates  among  different  races  are  well  known. 
The  black  race,  for  example,  always  suffers  a  higher  mortality  than 
the  white.  In  Boston  during  the  half  century  from  1725  to  1774  the 
death  rate  per  1,000  is  given  as  ranging  from  56  to  87  for  the  blacks 
and  only  from  30  to  41  for  the  whites.  Thus  the  maximum  white 
death  rate  was  lower  than  the  minimum  black  death  rate.*^ 

In  1906  the  death  rate  per  1,000  in  all  registration  cities  having  not 
less  than  10  per  cent  colored  inhabitants  was  17.2  for  whites  and  28.1 
for  blacks. 

These  racial  differences  may  be  ascribed  in  part  to  different  habits 
and  conditions  of  life,  but  probably  in  part  also  to  varying  racial 
susceptibility  to  disease. 

The  relation  of  social  status  to  the  rate  of  mortality  has  been  often 
discussed  and  offers  a  partial  explanation  of  racial  or  national  varia- 
tion of  death  rate.  That  a  well-to-do  class,  properly  fed  and  clothed 
and  with  opportunity  for  leisure,  will  be  less  susceptible  to  disease 
and  death  than  a  poverty-stricken  class,  ill-fed  and  overworked,  has 
been  repeatedly  shown  by  statistics.  Newsholme  has  stated,^  for  ex- 
ample, that  in  Glasgow  the  death  rate  among  tenants  of  large  houses 
is  much  lower  than  among  the  tenants  of  smaller  dwellings : 


One  and  two 
room  houses. 

Three  and 

four  room 

houses. 

Five  rooms 
and  over. 

27.7 

19.5 

11.2 

In  Paris  comparison  has  been  made  between  two  quarters  known  to 
be  rich,  on  the  one  hand,  and,  on  the  other,  a  third  quarter  known  to 

be  poor. 

Death  rate  per  1,000  population.'' 

Rich  quarters: 

Elysee 13.4 

Opera 16.  2 

Poor  quarter: 

Menilmontant 31.  3 


o  Lemuel  Shattuck,  "  The  Vital  Statistics  of  Boston,"  p.  xiii.  Reprinted  in 
"  Bills  of  Mortality,  1810-1849,"  city  of  Boston,  1898. 

6 Arthur  New.sholme,  "Vital  Statistics,"  London  (Swan  Sonnenschein),  1899, 
p.  163. 

c  E.  Levasseur,  "  La  Population  Francaise,"  Paris,  1891,  Vol.  II,  p.  403. 


KEPORT   ON    NATIONAL  VITALITY. 


23 


In  Russia  a  similar  comparison  has  been  made  between  peasants 
who  own  no  land,  those  who  own  less  than  13^  acres,  those  who  own 
between  13^  and  40^  acres,  and  so  on  up  the  scale  of  proprietorship." 

Peasant  death  rate  per  1,000,  Government  of  Voronezh,  1889-1891. 


Class  of  household. 


Per  1,000. 


Having  no  land 

Having  less  than  13.5  acres 

Having  13.5  and  less  than  40.5  acres 
Having  40.5  and  less  than  67.5  acres 
Having  67.5  and  less  than  135  acres 
Having  more  than  135  acres 


34.7 
32.7 
30.1 
25.4 
23.1 
19.2 


Occupational  comparisons  are  often  made ;  and  while  they  must  be 
handled  with  great  care,  especially  because  of  differences  in  age,  the 
following  may  be  said  to  display  roughly  the  variations  in  death 
rate  among  social  classes. 

Death  rate  of  males  per  1,000,  according  to  occupations,  for  registration  States, 

1900J> 

Mercantile   and  trading :l_  12. 1 

Clerical   and    oflacial 13. 5 

Professional  15.  3 

Laboring  and  servant 20.  2 

Special  industries  have  high  death  rates  from  special  diseases. 
Among  dusty  trades,  for  instance,  tuberculosis  is  very  common." 

Finally,  the  experience  of  industrial  life-insurance  companies, 
which  deal  largely  with  the  poorer  classes  of  society,  shows  a  higher 
death  rate  than  that  displayed  by  the  experience  tables  of  other  in- 
surance companies.*^ 

Insurance  mortality  per  1,000. 

Industrial 
A  „g  .  insurance,     insurance, 

°  ■  'Rncriish       Metropoli- 

tan Life. 


20 
25 
35 
55 
70 


10.5 
14.1 
17.2 
35.2 
91.0 


We  find  also  great  variations  in  death  rates  dependent  on  varying 
climatic  or  seasonal  conditions,  on  the  prevalence  or  absence  of  certain 
pests,  on  the  fluctuating  virulence  of  specific  diseases,  and  on  numer- 
ous natural  differences.  Other  significant  factors  in  mortality  are 
historical  events,  such  as  wars,  plagues,  and  epidemics.  Hard  times 
bring  increased  mortality,  whether  due  to  natural  or  politico-economic 
causes.  There  remain  to  be  mentioned  also  deaths  by  accident  in  all 
its  many  forms. 

« I.  M.  Rubinow,  "  Poverty's  Deatb  Rate,"  publications  of  the  American  Sta- 
tistical Association,  December,  1905,  p.  348. 

6  "  Twelfth  Census  of  the  United  States,"  Vol.  Ill,  p.  cclxi. 

c  See  Frederick  L.  Hoffman.  "  Mortality  from  Consumption  in  dusty  trades," 
Bulletin  No.  79  of  the  U.  S.  Bureau  of  Labor. 

"  Haley  Fiske,  "  Industrial  Insurance,"  The  Charities  Review,  March  1898,  p.  33. 

84369— No.  30—09 3 


24  REPOET   03Sr   NATIONAL  VITALITY. 

Section  5 — Mortality  historically. 

Not  only  does  the  death  rate  vary  greatly  from  place  to  place  and 
from  one  social  class  to  another,  but  it  changes  in  a  most  marked 
fashion  from  period  to  period  in  history.  The  records  of  old  cities 
show  that  a  decided  decrease  in  mortality  has  been  steadily  going  on. 
In  London,  for  example,  the  rate  per  1,000  has  fallen  from  50  in  1660- 
1679  to  15  in  1905,  a  decrease  of  TO  per  cent.  In  the  plague  years, 
1593, 1625, 1636,  and  1665,  the  death  rates  per  1,000  were  240,  310, 130, 
and  430.<»  The  "  black  death  "  in  1348-9  probably  swept  away  half 
of  the  population  in  many  localities  throughout  Europe.* 

Mortality  in  London.'^ 


Year. 

Rate  per 
1,000. 

1660-1679 

50 

1680-1728  b                                                      

80 

1729-1780                             

40 

1905                                                                       

15.1 

°  Kober,   loc.  cit.,  p.  25. 

*  These   years   include   the   period   of   pests. 

Within  a  quarter  century  London  has  cut  her  death  rate  in  half, 
while  Vienna,  if  we  may  trust  the  figures,  has  within  a  century  re- 
duced her  rate  from  60  per  1,000  of  population  to  23.^  Similarly,  the 
mortality  rate  in  Boston  has  been  lowered  from  an  estimated  34  per 
1,000  ^  in  1700  to  19  to-day. 

Mr.  John  K.  Gore,  actuary  of  the  Prudential  Insurance  Company, 
shows «  that  the  average  death  rates  per  1,000  of  population  among 
typical  American  cities  was,  for  the  white  population,  as  follows: 

Years.  Death  rate  per  1,000. 

1804-1825 24.  6 

1826-1850. 25.  7 

1851-1863. 28.3 

1864-1875  — 25.4 

1876-1888 22.9 

1889-1901 : 21.0 

The  record  even  of  the  last  thirty  years  displays  a  fall  in  death 
rates  that  may  inspire  us  with  buoyant  hope  for  the  future.  The 
mortality  rate  per  1,000  has  fallen  in  Berlin  from  33  in  1875  to  16 
in  1904 ;  in  Munich,  from  41  in  1871  to  18  in  1906 ;  and  in  Washing- 
ton, from  28  in  1875  to  19  in  1907.^ 

Between  1890  and  1906  New  York  lowered  her  death  rate  per  1,000 
from  25.4  to  18.6,  and  Boston  from  23.4  to  18.9.  The  mortality  rate 
in  the  whole  registration  area  of  the  United  States  fell  from  19.6 
per  1,000  in  1890  to  16.1  in  1906,  although  the  area  in  the  last-named 
year  included  a  larger  proportion  of  urban  population. 

o  See  Farr,  "  Vital  Statistics,"  London,  1885,  p.  131. 

&See  Abbot  Gasquet,  "The  Black  Death  of  1348  and  1349,"  London  (Bell), 
1893. 

"A.  F.  Weber,  "  The  Growth  of  Cities,"  New  York,  1899,  pp.  355,  356. 

^  Shattuck,  loc.  cit.,  pp.  xii-xiv. 

«  "  On  the  Improvement  in  Longevity  in  the  United  States  during  the  Nine-     ; 
teenth  Century." 

f  Kober,  loc.  cit.,  p.  25. 


REPORT   ON    NATIONAL  VITALITY.  25 

"We  have  also  vital  records  for  the  city  of  Habana,  running  back 
over  a  century.  These  show  that  while  the  death  rate  in  1802  was 
given  as  54.6  per  1,000,  rising  in  cholera  years  even  as  high  as  103.4 
(1833)  and  in  the  last  year  of  Weyler's  concentration  methods  as 
high  as  91,  the  rate  during  the  eight  years  from  1899-1906  ranged 
from  20.4  to  33.6.« 

These  records  also  show  the  remarkable  and  sudden  fall  that  may 
be  brought  about  by  a  change  in  the  living  conditions  of  a  community. 
During  the  three  "  concentration  "  years  of  1896,  1897,  and  1898 
the  mortality  rate  per  1,000  was  51.7,  78.7,  and  91,  respectively.  In 
1899,  the  first  complete  year  of  American  occupation,  the  rate 
dropped  to  33.6.  and  since  then  it  has  ranged  between  20.4  and  24.4. 
There  can  be  no  question  that  the  improvement  was  almost  wholly 
due  to  the  sanitary  reforms  introduced  by  Colonel  Gorgas,  and  the 
other  United  States  Army  surgeons  under  Gen.  Leonard  Wood. 

The  record  of  American  Army  sanitarians  in  the  Panama  Canal 
Zone  shows  as  striking  results  as  in  Cuba.  The  death  rate  in 
Panama  during  1887,  when  the  French  canal  companies  held  occu- 
pation, ran  over  100  per  1,000.  In  1906  the  death  rate  was  49  per 
1,000,  while  in  1907  it  fell  to  less  than  34.  Colonel  Gorgas  attributes 
the  decrease  in  the  general  death  rate  in  great  part  to  improved  sani- 
tation, though  he  adds  that  "  increased  wages,  better  food,  and  better 
clothing  have  no  doubt  played  a  considerable  part  in  the  general  im- 
provement of  the  health."^ 

Section  6. — Adult  and  infant  mortality. 

Mortality  varies  greatly  with  age.  The  improvement  in  the  city 
death  rate  of  the  past  half  century  has  been  especially  marked 
among  the  young. 

It  is  true  that  in  countries  of  the  same  degree  of  civilization  the 
infant  death  rate  is  remarkably  constant ,°  but  this  is  probably  ac- 
counted for  by  the  similarity  in  the  methods  of  feeding  of  infants. 
Certainly  where  there  is  a  difference  in  conditions  there  will  be 
found  a  difference  in  mortality.  Thus,  the  comparison  between  the 
mortality  of  infants  fed  on  cow's  milk  and  those  fed  on  mother's 
milk  shows  that  the  former  is  five  to  ten  times  that  of  the  latter.*^ 

Although  the  infant  mortality  rate  is  probably  falling,^  the  de- 
crease is  not  accompanied  by  a  lowering  of  the  mortality  of  later 
life.  There  is  an  increased  mortality  beyond  the  age  of  50  years. 
In  Massachusetts  the  death  rates  by  age  changed  during  thirty  years 
as  follows: 

"'  "  Report  of  the  National  Sanitary  Department  of  ttie  Republic  of  Cuba," 
Habana,  1906,  p.  78. 

*  Letter  from  Col.  W.  C.  Gorgas,  chief  sanitary  officer,  Canal  Zone. 

^  See  E.  B.  Phelps,  "A  Statistical  Study  of  Infant  Mortality,"  quarterly  pub- 
lication of  the  American  Statistical  Association,  September,  1908.  Mr.  Phelps 
shows  the  utter  unreliability  of  most  statistics  of  infants  under  1  year  of  age, 
especially  in  the  United  States. 

^  See  Harald  Westergaard,  •'  Mortalitat  uud  Morbilitat,"  Jena,  1901,  p.  364. 

^  Edward  E.  Graham,  M.  D.,  "  Journal  of  the  American  Medical  Association," 
September  26, 1908 ;  also  "  British  Medical  Journal,"  February  1, 1908,  p.  271. 


26  KEPOET   ON   NATIONAX,  VITALITY. 

Death  rate  in  Massachusetts  per  1,000  of  population  in  each  age  period.'^ 


Age. 

1865. 

1895. 

5-9                   

9.6 
5.1 
9.6 

12.6 

11.7 

12 

17 

33 

70 
168 

6.2 

10-14           

3.2 

15-19               

5.3 

20-29 

7.1 

30-39              

9.7 

40-49 

13 

50-59              

20 

60-69  

39 

70-79                

82 

186 

"  "  Vital  Statistics  of  Massachusetts,"  1856-1895,  p.  755. 

Here,  while  the  death  rate  for  all  age  periods  under  40  has  mate- 
rially decreased,  the  later  periods  of  life  have  suffered  progressive 
increases  in  mortality  rate.*^ 

As  Frederick  L.  Hoffman  has  expressed  it : 

There  is,  of  course,  no  question  whatever  that  the  American  death  rate,  using 
the  term  in  a  very  comprehensive  sense,  has  substantially  declined  within  the 
last  fifty  years,  but  it  is  equally  evident  that  this  decline  has  been  at  the  younger 
ages,  and  not  during  the  period  of  life  which,  economically,  is  of  the  greatest 
value.  There  is  no  doubt  that  the  mortality  of  adult  ages  is  still  decidedly 
excessive. 

The  same  tendency,  viewed  from  the  standpoint  of  the  expectation 
of  life,''  is  disclosed  in  the  study  of  two  Massachusetts  life  tables, 
compiled  nearly  a  century  apart — one,  Wigglesworth's  life  tables  for 
Massachusetts  and  New  Hampshire  in  1789,  though  not  very  accurate; 
the  other,  Abbott's  Massachusetts  life  tables  for  1893-1897. 

Expectation  of  life  in  Massachusetts. 


Age. 

1789. 

1897. 

Age. 

1789. 

1897. 

0 

35.5 
43.2 
34.2 
26 

45.4 
50 
42 
28.2 

60 

15.4 
5.9 
3.7 

15.1 

10 

80 

6.1 

20. 

90.  .        

3.4 

40 

These  figures  indicate  that  the  expectation  of  life  at  the  earlier 
ages  is  much  greater  than  a  century  ago,  but  that  for  the  age  of  60 
and  upward  it  has  remained  practically  stationary. 

<^At  first  sight  it  would  seem  that  this  increased  mortality  in  later  ages  could 
be  explained  away  as  due  to  the  larger  number  of  persons  who  are  saved  from 
earlier  death  and  tend  to  produce  a  higher  mortality  at  the  older  ages.  I  speak 
of  this  because  very  intelligent  persons  have  drawn  this  conclusion.  But  it  is 
obviously  fallacious,  since  the  figures  do  not  indicate  the  number  of  deaths  in 
different  periods,  but  the  death  rates  in  different  periods  of  life  per  1,000  at  each 
period.  There  are,  to  be  sure,  as  a  consequence  of  saving  lives  in  the  past, 
more  old  men  now  living  than  otherwise  there  would  be,  and  there  will  be  more 
deaths,  but  the  figures  show  that  these  old  deaths  have  increased  faster  than 
the  number  of  old  men.  This  fact  raises  the  suspicion,  therefore,  that  the 
lives  which  have  been  saved  by  the  hygiene  of  a  generation  ago  are  weak  lives. 
Whether  this  is  a  tenable  hypothesis  or  not  will  be  discussed  in  Chapter  X. 

*"  Expectation  of  life"  at  any  given  age  is  the  mean  after-lifetime  of  per- 
sons who  reach  that  age.  Thus  100  persons  have  an  expectation  of  life  of  50 
at  the  age  of  10,  if  the  total  life  to  be  lived  by  those  100  persons  before  death 
is  five  thousand  years. 


REPORT   ON    NATIONAL  VITALITY. 


27 


English  life  tables  ^  for  three  decades  ending  1900  display  the  same 
tendency. 

English  life  tables — Expectation  of  life. 


MALES. 


Age. 

1871-1880. 

1881-1890. 

1891-1900. 

0 

41.4 

39.4 

13.1 

4.8 

43.7 

40.3 

12.9 

4.5 

44.1 

20 

41 

00 

12.9 

80 

4.6 

FEMALES. 

0 

44.6 
41.7 
14.2 
5.2 

47.2 
42.4 
14.1 
5 

47.8 

20 

43.4 

60 

14.1 

80 

5.1 

These  tables  show  that  there  is  improvement  at  the  younger  ages 
for  the  period  1891-1900  over  the  period  1871-1880.  For  ages  over 
60  there  has  been  a  retrogression.  It  is  observable,  however,  that 
between  the  periods  1881-1890  and  1891-1900  the  figures  for  60  years 
have  remained  stationary,  and  for  80  have  slightly  improved. 

In  other  words,  a  baby  to-day  has  in  prospect  a  much  longer 
average  lifetime  than  did  the  baby  of  two  generations  ago;  but  a 
•man  or  woman  60  years  old  has  in  prospect  an  average  after  lifetime 
no  greater  than  formerly. 

The  proximate  cause  of  this  contrast  would  seem  to  lie  in  the  fact 
that  the  mortality  from  many  of  the  diseases  of  later  life  has  been 
and  is  on  the  increase.  The  death  rates  from  diabetes,  heart  disease, 
and  Bright's  disease  have  all  doubled  in  thirty  years.^ 

Cancer  is  probably  on  the  increase,''  and  "  to-day  one  in  every  21 
men  who  have  reached  the  age  of  35  and  one  in  every  12  women  who 
have  reached  35  eventually  die  of  that  disease."  ^ 

In  addition,  there  may  be  mentioned  other  diseases,  arteriosclerosis, 
nephritis,  apoplexy,  paresis,  disorders  of  the  liver,  and  all  manner  of 
degeneration,  all  of  them  maladies  of  adult  life,  and  all  of  them 
apparently  tending  to  increase. 

Section  7. — Particular  diseases. 

We  turn  now  to  the  ravages  made  by  particular  diseases  in  the 
modern  world.  The  death  rate  in  the  United  States  from  tuber- 
culosis of  all  forms  equals  the  combined  death  rate  from  small- 
pox, typhoid  fever,  diphtheria,  cancer,  diabetes,  appendicitis,  and 
meningitis. 

"  "  Supplement  to  Sixty-fifth  Annual  Report  Register-General  of  England  and 
Wales,"  pt.  1,  1907,  p.  XLVIII-LI. 

*  Norman  E.  Ditman,  M.  D..  "  Education  and  its  Economic  Value  in  the  Field 
of  Preventive  Medicine,"  Columbia  University  Quarterly,  Supplement  to  June, 
1908,  p.  38. 

"  Elie  Metchnikoff,  "  The  Nature  of  Man,"  English  translation,  New  York 
(Putnam),  1903,  pp.  213,  214;  see  also  "United  States  Census  mortality  statis- 
tics, 1906,"  p.  29. 

<*  Ditman,   loc.   cit.,   p.  38. 


28  EEPOKT   ON   NATIONAL  VITALITY. 

The  death  rate  from  tuberculosis  of  all  kinds  in  the  registration 
area  was  183.6  per  100,000  in  1907."  The  rate  is  high  among  negroes.* 
Large  as  these  figures  are,  they  represent  a  considerable  decrease 
since  lOOO.''     Tuberculosis  is  a  preventable  disease. 

On  a  par  with  tuberculosis  in  the  number  of  its  victims  in  this 
country  stands  pneumonia. 

The  mortality  statistics  of  the  last  census  show  that  in  the  registra- 
tion area  of  the  United  States  pneumonia  is  responsible  for  11  per 
cent  of  all  deaths.  Pneumonia  is  now  known  to  be  a  communicable 
disease,  the  germ  of  which  is  very  widely  distributed ;  but  there  is 
great  need  for  special  researches  into  the  modes  of  spreading  this 
formidable  disease.  In  the  meantime  the  best  protection  is  to  "  keep 
in  condition."  While  the  germ  of  pneumonia  is  the  exciting  cause  of 
the  disease,  predisposing  causes  are  acute  or  chronic  alcoholism,  ex- 
posure to  cold,  extreme  exhaustion,  and  debility  of  any  kind. 

Typhoid  fever  is  in  some  places  yielding  to  preventive  measures  in 
a  most  striking  manner.  The  fall  in  the  death  rate  from  typhoid  in 
the  registration  area  from  46.3  per  100,000  of  population  in  1890  to 
33.9  in  1900,^^  and  to  32.1  in  1906,^  may  be  safely  ascribed  to  improve- 
ments in  the  water  and  milk  supplies  of  our  cities.  The  surprising 
reduction  of  the  typhoid-fever  death  rate  in  individual  cities,  result- 
ing from  definite  improvements  in  the  water  supply,  gives  direct  con- 
firmation of  this  statement. 

The  typhoid  mortality  in  Munich  during  1856  was  291  per  100,000 
of  population.  The  city  at  that  time  contained  numerous  cesspools, 
and  the  water  supply  was  largely  obtained  from  wells  and  pumps. 
From  1856  to  1887  there  was  great  activity  in  the  filling  up  of  cess- 
pools, the  abandonment  of  pumps  and  wells,  and  the  installation  of 
modern  sewers.  A  pure  water  supply  was  also  secured,  the  water 
being  brought  from  a  distance.  The  typhoid-fever  death  rate  fell  in 
1887  to  10  per  100,000  of  population — a  reduction  of  97  per  cent.'' 

In  Hamburg  the  typhoid  mortality  for  1880-1892  ranged  from  24  to 
88,  averaging  39.7  per  100,000.  In 'May,  1893,  a  filtration  plant  was 
opened,  and  the  rate  fell  in  that  same  year  to  18.  ^  For  the  five  years 
following  it  averaged  only  7.2,  showing  a  reduction  of  over  80  per 
cent.^ 

The  introduction  of  a  water  filter  in  the  town  of  Lawrence,  Mass., 
in  1893  was  followed  by  a  reduction  in  deaths  caused  by  typhoid 
from  105  in  1892  to  22  in  1896,  one-fifth  the  previous  figure.     Filter- 

<*  For  a  careful  statistical  study  of  tuberculosis  see  "  Tuberculosis  in  the 
United  States,"  United  States  Census,  issued  for  the  International  Congress  on 
Tuberculosis,  190S.  See  also  "  Bulstrode's  Report  in  Thirty-fifth  Annual  Report 
of  (English)  Local  Government  Board,  1905-6,"  and  Arthur  Newsholme,  M.  D., 
"  Prevention  of  Tuberculosis,"  190S. 

*  For  the  prevalence  of  tuberculosis  in  the  negro,  see  F.  L.  Hoffman's  valuable 
monograph,  "The  American  Negro,"  publications  of  the  American  Economic 
Association,  August,  1896. 

"  This  decrease  is  shown  by  the  exact  figures  (not  estimated)  in  the  registra- 
tion area. 

<*  Twelfth  Census  of  the  United  States,  Vol.  Ill,  p.  cxliv. 

«  Mortality  Statistics,  U.  S.  Census  Office,  1906,  p.  30. 

^  Ditman,  loc.  cit.,  p.  17. 

3  A.  C.  Abbott,  M.  D.,  "  The  Hygiene  of  Transmissible  Diseases,"  Philadelphia, 
Saunders,  1899,  pp.  88-89. 


BEPORT   ON    NATIONAL  VITALITY.  29 

ing  the  city  water  in  several  other  American  cities  has  shown  abrupt 
declines  in  the  typhoid  death  rate  almost  as  remarkable.* 

Another  method  of  pointing  out  the  importance  of  a  pure  water 
supply  is  to  compare  the  mortality  rates  from  typhoid  fever  of  cities 
that  secure  water  from  various  sources  of  supply,  as  the  following 
table  shows :  * 

Death  rate  from  typhoid  fever  per  100,000  of  population,  1902-1906. 

4  cities  using  ground  water  from  large  wells 18. 1 

IS  cities  using  impounded  and  conserved  rivers  or  streams 18.  5 

8  cities  using  water  from  small  lakes 19.3 

7  cities  using  water  from  Great  Lakes 32.  8 

5  cities  using  surface  and  underground  water 45.  7 

19  cities  using  polluted  river  water 61. 1 

Thus  far  our  studies  indicate  that  typhoid  fever  will  cease  to  be  a  "  prob- 
lem "  in  any  community  having  clean  water  and  an  uninfected  milk  supply,  and 
in  which  cases  of  the  disease  are  treated  as  dangerous  and  contagious."  ^^ 

Unfortunately  such  communities  are  too  rare  at  present. 

Perhaps  the  most  common  and  neglected  source  of  danger  of  in- 
fection from  typhoid  is  the  ordinary  house  fly  or,  as  Dr.  L.  O.  How- 
ard, chief  of  U.  S.  Bureau  of  Entomology,  would  have  us  call  it, 
the  "  typhoid  fly." 

Smallpox,  another  disease  that  yields  readily  to  preventive  meas- 
ures, has  decreased  greatly  in  virulence  and  mortality  since  the 
introduction  of  vaccination.  In  Prussia,  for  example,  the  death 
rate  from  smallpox  per  100,000  population  was  24,4  in  the  period 
from  184G-18T0.  In  1874  vaccination,  which  up  to  that  time  had 
been  only  intermittently  utilized,  was  made  compulsory,  and  the 
death  rate  per  100,000  fell  at  once  to  1.5  for  the  years  1875-1886.'^ 

Other  European  States,  however,  have  been  more  lax  than  Ger- 
many. In  1886  the  death  rate  from  smallpox  in  Switzerland  was 
fifty-fourfold  that  of  Germany;  in  Belgium,  forty-eightfold;  in 
Austria,  eighty-onefold,  and  in  Hungary,  six  hundred  and  sevenfold.* 

Babbage  f  states  that  "  it  has  been  shown  by  M.  Duvillard  that  the 
introduction  of  vaccination  has  increased  the  mean  duration  of  human 
life  about  three  years  and  a  half."  Before  Jenner's  utilization  of 
vaccination  to  guard  against  smallpox  that  disease  was  causing  one- 
tenth  ^  of  all  deaths  of  the  human  race,  just  as  does  tuberculosis 
to-day,  while  "  nearly  twice  as  many  were  permanently  disfigured  by 
its  ravages.  In  England  300  per  100,000  population  died  annually 
from  it.  It  is  computed  that  during  the  eighteenth  century  50,000,000 
people  died  of  smallpox  in  Europe."  ^ 

0  See  Kober,  loc.  cit.,  pp.  18,  19. 

^Kober,  loc.  cit.,  p.  15. 

'^  M.  J.  Rosenau,  L.  L.  Lumsden,  and  Jos.  H.  Kastle,  "  The  origin  and  prev- 
alence of  typhoid  fever  in  the  District  of  Columbia,"  Hygienic  Laboratory 
Bulletin  No.  44,  1908,  p.  9. 

^Ditman,  loc.  cit,,  p.  8. 

« Floyd  M.  Crandall,  "A  century  of  vaccination,"  American  Medicine,  De- 
cember 7,  1901.  ' 

f  Loc.  cit,,  p.  8. 

s  Crandall,  loc,  cit,  p,  6, 

*  Ditman,  loc.  cit,,  pp.  6,  52-3. 


30  EEPOET   ON   NATIONAL  VITALITY. 

Boston  was  visited  twelve  times  by  smallpox  epidemics  in  the  cen- 
tury and  a  half  ending  1800." 

Yet  where  vaccination  has  been  made  compulsory,  or  where  it  is 
generally  resorted  to,  smallpox  has  virtually  disappeared.  The  last 
census  reported  but  3,500  deaths  from  smallpox  in  the  United  States 
in  1900.  Even  as  long  ago  as  1826  Denmark  was  enforcing  the  prac- 
tice of  vaccination  so  vigorously  that  not  a  single  case  had  appeared 
for  eleven  years.^  Habana,  during  the  eight  years  prior  to  the  Amer- 
ican intervention,  reported  3,132  deaths  from  smallpox.  In  1899, 
the  year  following  the  American  entry,  there  were  four  deaths,  and 
three  more  during  the  next  seven  years — a  virtual  uprooting  of  the 
disease." 

The  present  outcry  against  vaccination  is  based  on  a  misunder- 
standing, and  is  one  of  many  evidences  of  the  imperative  necessity 
of  the  diffusion  of  correct  knowledge  among  the  people  on  matters 
of  hygiene  and  preventive  medicine.  Whether  vaccination  should  be 
made  compulsory  is  a  fair  question,  but  that  it  is  efficacious  is  not 
open  to  question.  The  argument  that  because  some  unvaccinated 
persons  escape  during  an  epidemic  all  would  escape  is  too  absurd 
to  deserve  serious  consideration.'* 

Yellow  fever  first  appeared  in  serious  form  at  Philadelphia  in 
1793,  when  one-tenth  of  that  city's  population  died  of  it  in  the  space 
of  six  and  a  half  weeks.  Since  1793  the  United  States  has  had  500,- 
000  cases,  resulting,  it  is  estimated,  in  about  100,000  deaths.  In 
1900  it  was  discovered  that  a  species  of  mosquito  is  responsible  for 
the  transmission  of  this  fever,  and  in  consequence  of  this  knowledge 
and  its  application  the  disease  is  now  practically  banished  from  this 
country.^ 

The  marked  decrease  in  the  death  rate  from  yellow  fever  in  Ha- 
bana since  the  American  intervention  in  1898  is  shown  in  the  fol- 
lowing table.  The  deaths  from  yellow  fever  numbered  4,420  in  the 
eight  years  from  1891  to  1898,  while  in  the  eight  years  from  1899 
to  1906  they  numbered  but  465. 

<»  Shattuck,  loc.  cit,  p.  xiv. 

*  Crandall,  op.  cit. 

"  Report  of  National  Sanitary  Department  of  tlie  Republic  of  Cuba,  Habana, 
1906,  p.  79. 

^  For  the  most  scientific  statistical  studies  of  vaccination  see  W.  R.  Mac- 
donnell,  Biometrika,  Vol.  I,  1902,  p.  375,  and  Vol.  II,  1903,  p.  135.  J.  Brown- 
lee,  Biometrika,  Vol.  IV,  1905-6,  p.  313.  F.  M.  Turner,  Biometrika,  Vol.  IV, 
p.  483.  Karl  Pearson,  Biometrika,  Vol.  IV,  and  Pbilosophical  Transactions  of 
the  Royal  Society  of  London,  Series  A,  Vol.  195,  p.  43.  Humphreys,  Journal  of 
the  Royal  Statistical  Society,  1897,  p.  503.  For  the  best  of  antivaccination  lit- 
erature see  Alfred  Russell  Wallace,  "  The  Vaccination  Delusion,"  and  Milnes, 
Journal  Royal  Statistical  Society,  1897,  p.  552  (Comment  by  G.  U.  Tale,  p.  608). 
For  both  sidos  see  Report  of  the  Royal  Commission  on  Vaccination,  1897. 

^Ditman,  lvic,  cit.,  pp.  11-12. 


KEPORT   ON    NATIONAL  VITALITY. 


31 


Yellow-fever  death  rate  in  Habana,  1870-1906. 
[Rate  per  100,000  population."] 


Before  American  intervention. 

After  American  intervention. 

1870... 
1880.. 

..  300.5 
..  324.5 
..  153.6 
..  275.8 
..  639.5 
..  428 

1898. . . 
1899... 

. . .     07. 8 
. . .     42.  5 

1890... 
1895... 
1896. . . 
1897... 

1900.... 
1901... 
1902... 
1903     . 

...  124.0 
...       6.9 
...       0 
0 

1904... 
1905... 
1906... 

• 

...       0 
. . .       8.  0 
...       4.3 

"  Report  of  the  National  Sanitary  Department  of  the  Republic  of  Cuba,  1906,  p.  79. 

These  results  have  been  due  partly  to  the  elimination  of  the 
contagion-carrying  mosquito  and  partly  to  the  general  improvement 
of  the  city's  sanitary  appointments. 

A  similar  contrast  might  be  drawn  between  the  death  rates  from 
yellow  fever  at  Panama  during  the  efforts  of  the  French  to  dig  the 
canal  and  during  the  American  work  under  the  sanitary  regulations 
of  Colonel  Gorgas.  If  the  same  thoroughgoing  measures  used  in 
Habana  and  at  Panama  were  employed  among  our  own  people,  the 
resultant  blessings  would  be  almost  equally  striking. 

The  impressive  figures  just  presented,  showing  the  fall  in  mortality 
from  so  many  of  the  most  dangerous  diseases,  point  clearly  to  the 
value  of  preventive  measures  in  the  conflict  with  disease.  The  fall 
in  tuberculosis  mortality  is  directly  due  to  the  growing  use  of  hospi- 
tals, which  have  tended  to  isolate  °'  consumptives,  and  to  a  use  of  our 
recently  acquired  knowledge  of  the  efficacy  of  fresh  air  and  the  out- 
door life;  typhoid  fever  has  virtually  disappeared  when  water  and 
milk  supplies  have  been  made  pure,  the  open  privy  abolished,  and 
flies  and  other  carriers  of  the  sjDecific  cause  of  the  disease  have  been 
provided  against ;  smallpox  has  given  way  before  vaccination ;  yellow 
fever  is  fast  disappearing  now  that  the  agent  of  transmission  is 
known ;  while  many  of  the  less  serious  diseases  are  losing  their  power, 
purely  owing  to  preventive  methods. 

Some  diseases,  once  the  scourges  of  humanity,  have  practically 
disappeared  from  the  civilized  world. 

Scurvy  up  to  the  latter  half  of  the  eighteenth  century  decimated 
the  armies  and  fleets  of  Europe  and  afterwards  proved  a  menace  to 
the  civilized  population.  During  Anson's  famous  expedition  about 
the  year  1750,  600  out  of  900  died,  chiefly  from  scurvy.  The  use  of 
lime  juice  and  fresh  vegetables  has  practically  eradicated  the  disease.* 

"  Cholera  was  wont  to  visit  the  cities  of  the  Atlantic  coast  in  the 
past  about  every  ten  years,  and  it  was  a  standing  menace  to  the  world 
every  summer.  It  was  not  uncommon  for  the  disease  to  decimate 
whole  towns  and  cities.  Since  the  discovery  of  its  cause,  however,  it 
has  been  robbed  of  its  terrors,  and  the  children  of  to-day  will  prob- 
ably never  know  of  it  except  by  name." 

Malaria  has  been  on  the  decrease  ever  since  the  discovery  that  the 
malarial  organism  is  transported  by  a  species  of  mosquito.     Even  the 

"  See  Arthur  Newsholme,  "  The  phthisic  death  rate,"  Journal  of  Hygiene, 
July,  1906. 

*  Ditman,  loc.  cit.,  14-15. 


32 


KEPOKT   ON    NATIONAL  VITALITY. 


five  years  ending  1906  show  a  progressive  decline  in  the  death  rate 
from  malarial  fever  in  the  registration  area.  The  figures  are  6.4,  4.3, 
4.2,  3.9,  and  3.5  deaths  per  100,000  of  population,  for  the  five  years  in 
question.  In  themselves,  the  figures  are  so  small  as  to  show  the  virtual 
disappearance  of  the  disease,  at  least  from  the  Northern  States.  It 
is  still  very  common  in  the  Southern  States.  Its  evil  is  by  no  means 
to  be  measured  by  the  deaths  it  causes.  It  produces  chronic  disability 
and  predisposes  to  other  diseases.* 

Finally,  the  furnishing  of  pure  milk  to  the  infant  population  of  the 
cities  is  eliminating  year  by  year  the  infant  scourges — diarrheal  dis- 
eases and  related  maladies. 

There  are  of  course  diseases  which  show  no  sign  as  yet  of  decreas- 
ing. The  census  volume,  "Mortality  Statistics  of  1906"  (p.  29) 
gives  only  one  important  disease  (diabetes)  as  actually  on  the  increase 
within  the  registration  area,  but  several  which  are  given  as  having 
"  fluctuating  rates,"  such  as  cancer,  heart  disease,  and  Bright's  disease, 
seem  still  to  have  an  upward  trend. 

It  is  known  that  malaria  is  preventable.  Why,  then,  is  it  not  pre- 
vented in  the  South  ?  Probably  for  two  reasons.  First,  the  facts  are 
not  generally  known,  owing  to  lack  of  vital  statistics  in  the  Southern 
States.  Second,  owing  largely  to  this  ignorance  no  adequate  effort 
has  yet  been  made.  As  an  example  of  what  can  be  done  we  have  the 
cleaning  of  Habana  by  Colonel  Gorgas.  The  following  table,  sup- 
plied by  him,  shows  the  deaths  from  malaria  from  1899  to  1907 : 


Year. 

Number 

of 
deaths. 

Year. 

Number 

of 
deaths. 

1S99                     

909 
325 
151 
77 
51 

1904 

44 

J900                                                  

1905 

32 

1901                              

1906 

26 

1902                  

1907 

o23 

1903           

"  Annual  Report  of  the  Sanitary  Department  for  the  City  of  Habana  for  the  year  1907. 

"  The  first  year  quoted,  1899,  the  malarial  deaths  were  excessive, 
owing  to  the  crowding  into  the  city  of  the  '  reconcentrados '  and  the 
starvation  and  misery  thereby  involved. 

The  next  year,  1900,  was  about  the  normal  rate.  The  next  year, 
1901,  begins  to  show  the  effect  of  the  antimalarial  work  done  in  con- 
nection with  the  yellow-fever  work;  1901  was  the  first  year  of  mos- 
quito work  in  Habana.  The  last  year,  1907,  shows  only  23  deaths 
from  malaria.  This  means  practically  the  extinction  of  malaria  in 
Habana.  The  item  of  23  deaths  in  1907  from  malaria  would  probably 
be  covered  by  the  malarial  cases  coming  in  from  the  rural  districts 
and  by  mistakes  in  diagnosis." 

The  preventability  of  accidents  is  beginning  to  be  appreciated.  It 
is  now  proposed  by  Mr.  W.  H.  Tolman  to  establish  in  New  York  a 
museum  of  safety  and  sanitation  to  demonstrate  this  fact.  Mr. 
Frederick  L.  Hoffman,  statistician  of  the  Prudential  Insurance  Com- 
pany, estimates  the  number  of  deaths  among  male  workers  alone  in 
1908  as  between  30,000  and  35,000.» 

«  See  "  Report  to  tlie  Conservation  Commission"  of  L.  O.  Howard.     "  Eco- 
nomic loss  to  the  people  of  the  United  States  through  insects  that  carry  disease." 
^  "  Industrial  accidents,"  Bulletin  of  the  Bureau  of  Labor,  1908. 


w 


Part  II.— THE  BREADTH  OF  LIFE  VERSUS  INVALIDITY, 

Chapter  III. — P7'evalence  of  serious  illness. 
Section  1 — Loss  of  time. 

Length  of  life  is  but  one  indication  of  vitality.  Everyone  recog- 
nizes that  the  life  of  a  valetudinarian  or  an  invalid,  however  long,  is 
but  a  narrow  stream.  We  may  therefore  conceive,  besides  the  dimen- 
sion of  length,  another  dimension  of  life  which  may  be  called  its 
"  breadth."  By  the  breadth  of  life  we  mean  its  healthiness.  Just 
as  length  of  life  is  limited  by  and  opposed  to  mortality  or  death,  so 
breadth  of  life  is  limited  by  and  opposed  to  invalidity  or  illness. 

An  ideally  healthy  life,  free  throughout  from  ailment  and  dis- 
ability, is  rarely  if  ever  found.  But  it  is  the  aim  of  hygiene  to  ap- 
proximate such  an  ideal.  Some  persons  imagine  that  length  of  life 
can  be  purchased  only  at  the  expense  of  breadth,  and  counsel  the 
deliberate  shortening  of  one's  life  for  the  sake  of  living  it  faster.  In 
exceptional  cases  such  a  policy  may  be  justified,  but  the  study  of 
longevity  reveals  the  fact  that,  as  a  rule,  length  and  breadth  of  life 
are  not  opposed,  but  that,  on  the  contrary,  the  one  can  seldom  be 
increased  without  an  increase  of  the  other.  Centenarians  are  usually 
persons  w^ho  have  been  exceptionally  free  from  illness'^  and  who 
have  performed  a  large  amount  of  work.  This  work  is  usually 
physical  labor  out  of  doors,  although  the  few  mental  workers  com- 
pleting the  century  have  also  lived  busy  lives. 

Chevreul,  the  distinguished  French  chemist  .who  died  twenty  years 
ago  at  the  age  of  103,  lived  a  life  of  great  activity  and  usefulness  as 
laboratory  experimenter,  as  industrial  chemist,  as  university  pro- 
fessor, and  as  a  writer  and  lecturer.  It  was  said  of  Alexander  Von 
Humboldt,  who  was  90  at  the  time  of  his  death,  that  he  had  not  only 
lived  twice  as  long  as  others  in  years,  but  that  in  work  accomplished 
he  had  lived  twice  as  much  per  day,  thus  enjoying  four  times  the 
average  lifetime. 

It  is  shortsighted  to  spend  more  vitality  each  day  than  we  earn. 
Such  a  policy  must  not  only  prove  suicidal  sooner  or  later,  but  tends 
to  narrow  one's  life  in  every  way  long  before  the  arrival  of  death. 
The  ordinary  individual  burns  the  candle  at  both  ends.  The  result 
is  an  almost  universal  invalidism  in  some  degree.  While  statistics 
are  lacking,  a  wide  observation  seems  to  justify  the  conclusion  that 
it  is  difficult  to  find  a  man  or  woman  over  40  whose  health  has  not 
become  impaired  in  some  manner.  Few  who  have  not  studied  the 
facts  realize  how  common  illness  is,  although  we  all  know  it  is  suf- 
ficiently common  to  make  the  question  "  How  are  you?"  the  ordinary 
form  of  salutation. 

<^  Metclinikoff,  "  The  Prolongation  of  Life,"  English  translation,  New  York, 
{Putnam's)   1908,  p.  145. 

33 


34:  EEPOKT    ON    ISTATIONAlj   VITALITY.  * 

Serious  illness  is  such  as  totally  incapacitates  a  person  from  work, 
whether  or  not  he  is  confined  to  his  bed.  The  burden  of  serious  ill- 
ness is  felt  in  several  distinct  ways.  There  is  the  annual  idleness  en- 
tailed by  this  illness,  the  cost  of  maintaining  institutions  devoted  to 
the  care  of  the  sick,  and  the  cost  to  the  individual  of  medicines,  medi- 
cal service,  and  nursing. 

The  amount  of  invalidity  or  illness  in  a  community  has  been  esti- 
mated by  a  number  of  different  investigators,  and  in  a  number  of  dif- 
ferent ways.  While  the  results  vary  somewhat,  on  the  whole  they 
harmonize  fairly  well.'* 

The  most  careful  consideration  of  the  various  illness  statistics  avail- 
able was  made  by  FaiT.  He  finds  that  the  rate  of  invalidity  increases 
with  age,  and  at  the  later  ages  increases  with  great  rapidity.  _  The 
material  he  has  used  has  come  chiefly  from  various  friendly  societies 
in  Great  Britain  and  Scotland,  and  especially  from  the  East  India 
Company.  His  final  conclusion  is  probably  nearly  as  valid  to-day  as 
then.  It  is  that  corresponding  to  each  death  in  a  community,  there 
are  a  little  more  than  two  years  of  illness. 

Another  way  of  expressing  the  same  fact  is  that  for  each  annual 
death,  there  are  on  the  average  two  persons  constantly  sick  during  the 
year.  Applying  this  estimate  to  the  United  States,^  in  which  about 
1,500,000  persons  die  per  annum,  there  are  probably  at  all  times  about 
3,000,000  persons  seriously  ill.  This  means  an  average  of  thirteen 
days  per  annum  for  each  inhabitant." 

Returns  gathered  from  79  benefit  societies  in  Scotland,  aggregating 
over  100,000  members,  and  based  on  the  experience  of  various  periods 
between  1750  and  1821,  showed  that  the  average  duration  of  sickness 
for  each  member  under  seventy  years  of  age  was  ten  days  per  year,  2 
of  which  were  assumed  to  be  "  bedfast "  days,  five  as  days  of  walking 
sickness,  and  three  as  days  of  permanent  sickness.*^ 

Section  2 — Particular  diseases. 

It  has  been  estimated  that  the  number  of  persons  in  the  United 
States  constantly  suffering  from  tuberculosis  reaches  500,000.  Of  this 
number  probably  about  half  are  totally  incapacitated,  while  the  re- 
mainder are  able  to  earn  about  half  of  the  ordinary  wages,^ 

<^  See  Farr,  Vital  Statistics,  London,  1S85,  pp.  501-514.  Harald  Westergaard, 
Mortalltat  und  Morbilitat,  Jena,  1901,  p.  683.  See  also  a  pamphlet  by  Hiram  J. 
Messenger,  actuary  of  the  Travelers'  Insurance  Company,  Hartford  "  The  Rate 
of  Sickness;"  Pettenkofer,  ^quoted  by  Uffelman,  Handbuch  der  Hygiene,  p.  3. 
Edwin  Chadwick,  "  The  Health  of  Nations,"  ed.  by  B.  W.  Richardson,  2  vols. 
(Longmans),  London,  1887,  Vol.  I,  p.  57 ;  Mayo-Smith,  "  Statistics  and  Sociology," 
New  York,  (Macmillan)  1895,  p.  158;  "  Statistische  Jahrbuch  fiir  das  Deutschen 
Reich,  1908,"  pp.  304-305. 

*  Judging  from  the  experience  of  sickness  insurance,  there  is  more  sickness  in 
the  United  States  than  in  England.  See  Dr.  Edward  Jarvis,  "  Political  Econ- 
omy of  Health,"  Fifth  Report  of  Mass.  Board  of  Health,  1874.  Dr.  Jarvis  also 
points  out  that  estimates  of  illness  are  based  on  experience  of  provident  persons 
among  whom  illness  is  a  minimum,  and  that  the  estimates  of  illness  take  no 
account  of  chronic  ailments  or  "  decrepitude." 

c  Farr,  Vital  Statistics,  p.  513. 

^  Edwin  Chadwick,  "The  Health  of  Nations,"  vol.  1,  pp.  56-57. 

« Irving  Fisher.  "  The  Cost  of  Tuberculosis  in  the  United  States  and  Its  Re- 
duction," paper  read  before  International  Congress  on  Tuberculosis,  "Washing- 
ton, 1908 ;  see  also  Huber,  "  Consumption  and  Civilization,"  Philadelphia,  1906 ;. 
and  Bardswell,  "  The  Consumptive  Workingman,"  London,  1906. 


KEPORT    ON"    NATIONAL   VITALITY.  35 

For  every  death  from  tj'^phoid  fever,  there  are  about  8  cases  of  ill- 
ness, averaging  seventy-five  days  of  incapacity.  But  this  is  not  the 
only  loss.  Professor  Sedgwick  has  said,  "  Hazen's  theorem  asserts  that 
for  every  death  from  typhoid  fever  avoided  by  the  purification  of  a 
polluted  public  water  supply  two  or  three  deaths  are  avoided  from 
other  causes.  Working  under  my  direction  Mr.  Scott  MacNutt  has 
recently  been  able  to  confirm  this  surprising  theorem,  and  even  to 
establish  it  as  conservative.  We  have  also  gone  further  than  Hazen 
and  discovered  what  the  other  causes  are  from  which  deaths  are  thus 
avoided ;  and,  although  our  results  are  not  yet  all  published,  I  may  say 
that  conspicuous  among  these  are  pneumonia,  pulmonary  tuberculosis, 
bronchitis,  and  infant  mortality."  <^ 

The  prevalence  of  the  hook-worm  disease  in  the  South  has  been  a 
matter  of  investigation  for  several  years  by  Doctor  Stiles  ^  of  the 
Public  Health  and  Marine-Hospital  Service.  The  disease  is  remarka- 
ble not  so  much  for  its  fatality,  though  that  is  large,  as  for  the  chronic 
incapacity  for  work  which  it  produces.  For  this  reason  the  hook 
worm  has  been  nicknamed  the  "  germ  of  laziness."  The  disease  ex- 
tends over  the  whole  South,  and  is  responsible  for  a  large  part  both 
of  the  sickness  (the  so-called  "  laziness  ")  and  of  the  poverty  of  the 
"  white  trash." 

There  are  no  satisfactory  statistics  as  to  the  extent  of  hook-worm 
disease ;  but  it  has  been  estimated  that  the  sufferers  are  incapacitated 
for  labor  from  one-fourth  to  one-half  of  their  time.  Most  striking  is 
the  fact  that  the  disease  is  easily  preventable  through  the  introduction 
of  sanitary  measures  as  well  as  curable  by  the  proper  (drug)  treat- 
ment of  the  present  victims.  It  has  been  largely  eradicated  from 
Porto  Rico."  Hook-worm  disease  weakens  when  it  does  not  kill  and 
is  known  to  be  a  precursor  of  tuberculosis. 

Malaria  is  one  of  the  diseases  which  are  fatal  relatively  seldom,  but 
which  shorten  life  by  predisposing  to  other  causes  of  death,  and  nar- 
row life  by  reducing  working  efficiency  by  a  large  percentage.  Doctor 
Howard  states  that  each  year  there  are  probably  3,000,000  cases  of 
malaria  in  the  United  States,  most  of  which  are  in  the  South.  This 
is  practically  all  preventable.*^ 

Dr.  Prince  A.  Morrow  says  that  the  number  of  syphilitics  in  the 
United  States  has  been  estimated  at  2,000,000.  This  disease  is  not 
only  in  itself  a  danger,  but  it  also  causes  a  large  number  of  diseases 
of  the  circulatory  and  nervous  systems. 

Doctor  Morrow  says  that  the  extermination  of  social  diseases 
would  probably  mean  the  elimination  of  at  least  one-half  of  our  insti- 
tutions for  defectives.  The  loss  of  citizens  to  the  State  from  the 
sterilizing  influence  of  gonorrhea  upon  the  productive  energy  of  the 
family,  and  the  blighting  destructive  effect  of  syphilis  upon  the  off- 
spring are  enormous.     In  the  opinion  of  very  competent  judges  social 

aW.  T.  Sedgwick,  "The  Call  to  Public  Health,"  Science,  1908,  p.  198. 

*  "■  Report  upou  the  Prevalence  and  Geographic  Distribution  of  Hook-worm 
Disease  in  the  United  States,"  Hygienic  Laboratory,  Bulletin  No.  10,  February, 
1903,  Washington. 

c  "  Reports  of  Commission  on  the  Suppression  of  Uncinariasis,  1904,  1905, 
1906-7,  1907-8,  San  Juan,  P.  R."  This  commission  has  been  succeeded  by  a 
bureau,  the  "  Anemia  dispensary  service." 

^  See  L.  O.  Howard,  Report  to  Conservation  Commission,  "  Economic  loss  to 
the  people  of  the  United  States  through  insects  that  carry  disease." 


"36  EEPORT    ON    ISTATIOISrAL   VITALITY. 

disease  constitutes  the  most  powerful  of  all  factors  in  the  degenera- 
tion and  depopulation  of  the  world. 

Among  the  troops  stationed  in  the  Philippines,  the  venereal  mor- 
bidity during  the  year  1904  was  297  per  1,000,  largely  exceeding  the 
morbidity  from  malarial  fevers  and  diarrhea;  22  out  of  every  1,000 
soldiers  were  constantly  ineffective  from  venereal  diseases,  four  times 
as  many  as  from  any  other  disease. 

The  statistics  of  the  Navy  Department  show  during  the  same  year, 
that  venereal  disease  was  chargeable  with  a  percentage  of  25.2 
of  the  total  number  of  sick  days  in  the  hospital  from  all  causes 
combined.  In  four  years  949  men  were  discharged  from  the  navy 
for  disability  from  venereal  disease.  The  statistics  of  the  English 
army  show  that  among  the  troops  stationed  in  India  537  per  1,000 
were  admitted  to  the  hospital  for  venereal  disease.  Of  the  troops  re- 
turning home  to  England  after  completing  their  timeof  service  in 
India,  25  per  cent  were  found  to  be  infected  with  syphilis. 

No  statistics  exist  for  venereal  disease  in  civil  life.  It  may  be  more 
prevalent  than  in  the  Q.Tmj  and  navy  service,  since  the  inhibitory 
influence  of  military  restraint  and  discipline  do  not  exist  and  the 
opportunities  for  licentious  relations  are  more  abundant. 

Neisser,  a  distinguished  German  authority,  states  that  "  fully  75 
per  cent  of  the  adult  male  population  contract  gonorrhea  and  15  per 
cent  have  syphilis." 

What  syphilis  and  gonorrhea  represent  in  the  lowered  working 
efficiency  of  our  population — to  say  nothing  of  the  still  more  impor- 
tant subject  of  increased  mortality — is  impossible  to  estimate;  but  it 
would  be  difficult  to  overemphasize  the  grave  danger  to  national  ef- 
ficiency from  these  and  the  other  venereal  diseases.  And  here  again 
the  most  striking  point  is  that  the  venereal  diseases  are  preventable. 

Alcoholism  and  drug  addiction  are  maladies  of  frightful  preva- 
lence. They  are  so  familiar  as  to  be  taken  by  many  as  a  matter  of 
course. 

Venereal  diseases  and  inebriety,  whether  alcoholic  or  drug,  fre- 
quently lead  to  insanity.  Statistics  are  not  yet  able  to  prove  con- 
clusively that  insanity  is  increasing,  though  this  is  the  opinion  of  the 
best  judges." 

Dr.  C.  L.  Dana,  formerly  president  of  the  New  York  Academy  of 
Medicine,  believes  the  increase  in  insanity  to  be  real  as  well  as  ap- 
parent. He  says :  "  The  annual  increment  of  insane  in  Massachusetts, 
according  to  the  Massachusetts  board  of  lunacy,  is  400  in  about  10,000, 
or  4  per  cent."  At  this  ratio  the  annual  increment  for  the  United 
States  would  be  approximately  5,600.  "  We  may  say  that  in  the  last 
twenty -five  years  the  ratio  of  insane  to  sane  has  shown  an  apparent 
gradual  increase  from  1  to  450  to  1  to  300,  and  this  latter  seems  to  be 
about  the  ratio  in  those  communities  of  North  America  and  Europe  in 
which  modern  conditions  of  civilization  prevail.  This  average  has 
varied  but  little  in  the  last  few  jea.rs ;  the  slight  yearly  increase  prob- 
ably will  not  change  rapidly  and  probably  not  continue,  for  when  the 
increase  in  the  insane  reaches  a  certain  point  of  excess  society  will 
have  to  take  notice  of  it  and  correct  it."  ^    There  are  no  accurate  fig- 

'^  For  a  critical  examination  of  statistical  data  on  insanity,  see  Humphreys, 
(Noel,  A.),  "The  alleged  increase  of  insanity,"  Journal  of  the  Royal  Statisti- 
cal Society,  June,  1907. 

^  "  Psychiatry  in  its  Relation  to  Other  Sciences,"  section  on  psychiatry  at  the 
International  Congress  of  Arts  and  Sciences,  St.  Louis,  September,  1904. 


KEPORT    ON    NATIONAL   VITALITY.  37 

ures  of  the  number  of  insane.  Mr.  Sanborn  estimates  that  the  number 
exceeds  250,000  in  the  United  States. 

Among  defective  and  disabled  classes  are  to  be  especially  mentioned 
the  feeble-minded,  paral3'tic,  crippled,  blind,  and  deaf  mutes.  The 
aggregate  disability  of  these  groups  is  greater  than  is  commonly 
recognized.    The  preventability  is  still  less  appreciated. 

With  reference  to  the  losses  each  year  from  industrial  accidents: 

The  statistical  report  of  the  Interstate  Commerce  Commission  for 
the  year  ending  June  30,  1907,  shows  that  during  that  year  11,800 
persons  were  killed  and  111,000  injured  on  our  American  railways, 
these  figures  including  passengers,  employees,  and  all  other  persons. 
A  large  number  of  the  victims  were  railway  employees,  for  whose 
safety  Congress  has  passed  a  number  of  laws.  The  total  number  of 
cases  of  industrial  accidents  can  not  be  estimated,  owing  to  the  lack 
of  statistical  information ;  but  Census  Bulletin  83  gives  the  number  of 
deaths  by  accident  and  violence  in  1900  at  57,500. 

"  Of  29,000,000  workers  in  the  United  States  over  500,000  are  yearly 
killed  or  crippled  as  a  direct  result  of  the  occupations  in  which  they 
are  engaged — more  than  were  slain  and  wounded  throughout  the 
whole  Eusso-Japanese  war.  More  than  one-half  this  tremendous  sac- 
rifice of  life  is  needless."  ° 

Mr.  Frederick  L.  Hoffman  estimates  *  that  the  number  of  accidents 
among  men  employed  in  the  United  States  in  1906  was  208,000,  of 
which  about  5,000  were  fatal.  These  figures  are  exclusive  of  mining, 
railway,  and  shipping  accidents. 

John  Mitchell  ^  estimates  that  for  every  100,000  tons  of  coal  pro- 
duced in  the  United  States  one  mine  worker  is  killed  and  several 
injured.  In  1907  the  figures  were  2,500  coal  miners  killed  and  6,000 
seriously  injured. 

In  Wisconsin  from  October  1,  1906,  to  October  1,  1907,  the  total 
number  of  accidents  reported  which  incapacitated  the  victim  by  at 
least  two  weeks  was  13,572.  The  accidents  to  employees  constituted 
53  per  cent  of  this  number.*^ 

Special  trades  have  special  perils  for  workmen.  "Among  diseases 
to  which  workmen  are  most  often  subject  are  the  so-called  '  inanition, 
scrofula,  rachitis,  pulmonary  consumption,  dropsy ; '  also  rheumatic 
troubles,  pleurisy,  typhoid  fever,  gangrene,  and  the  various  skin  dis- 
eases. Every  epidemic,  be  it  typhoid,  smallpox,  scarlet  fever,  dysen- 
tery, cholera,  etc.,  draws  its  greatest  army  of  victims  from  this  class. 
For  every  death  that  occurs  among  the  richer  and  higher  classes 
there  are  many  in  the  working  class.  It  is  the  workman  engaged  in 
unhealthy  factories  first  of  all  who  fills  the  hospitals  and  their  death 
chambers."  ^ 

It  is  the  pollution  of  the  air  breathed  by  workmen,  whether  the 
pollution  come  through  poisons  or  through  dust,  that  makes  many 
trades  dangerous.    Among  poisonous  trades  are  the  many  lead-using 

"  Ditman,  loc.  cit.,  43. 

^  In  an  article  contributed  to  the  "  New  Encyclopedia  of  Social  Reform,"  1908. 

<>  Speech  before  the  Governor's  Conference  on  Conservation,  White  House, 
May,  1908. 

^  Thirteenth  biennial  Report,  Bureau  of  Labor  and  Industrial  Statistics,  Madi- 
son, Wis.,  1908. 

^  C.  F.  W.  Doehring,  "Factory  Sanitation  and  Labor  Protection,"  Bulletin 
Department  of  Labor  No.  44,  January,  1903,  p.  2. 


38  REPOET   ON   NATIONAL  VITALITY. 

industries,  foundries,  and  chemical  factories.  Investigations  of  the 
dust-producing  trades  have  been  made,  showing  the  results  on  the 
respiratory  systems. 

Hirt's  statistics  show  that  men  employed  in  dust-producing  occu- 
pations suffer  much  more  frequently  from  pneumonia  and  consump- 
tion than  do  those  not  exposed  to  dust.  The  relative  frequency  of 
these  diseases  per  100  workmen  is  as  follows: 

Cases  of  consumption  and  jmetimoma  per  100  workers  in  certain  occupations. 


Workers  in  metallic  dust 

Workers  in  mineral  dust 

Workers  in  mixed  dust 

Workers  in  animal  dust 

Workers  in  vegetable  dust. . . 
Workers  in  nondusty  trades. 


Consump- 

Pneu- 

tion. 

monia. 

28 

17.4 

26.2 

5.9 

22.  G 

6.0 

20.8 

7.7 

13.3 

9.4 

11.1 

04.6 

"  George  M  Kober,  M.  D.,  "  Industrial  Hygiene,"  Bulletin  of  Bureau  of  Labor,  March, 
1908,  p.  477. 

Mr.  Owen  R.  Love  joy,  secretary  of  the  national  child-labor  com- 
mittee, has  condensed  a  table  from  Indiana  reports  <'  showing  the  high 
injury  rate  suffered  by  children  in  the  industries. 

Injuries  to  children  in  Indiana,  1907. 

^     ^   ..    ■    ■        1  /  5  per  1,000 

Proportion  of  adults  injured 1  3  pgj,  -j^^  qqq 

^          .■         ^    ^.,^         •    •       ^  /20  per  1,000 

Proportion  of  ctiildren  injured j^q  p^^.  ^  qqq 

The  injury  rate  for  children  is  shown  to  be  three  to  four  times  as 
great  as  for  adults. 

Chapter  IV. — Prevalence  of  minor  ailments. 

Section  1. — Importance  of  minor  ailments. 

The  statistics  of  morbidity  which  we  have  given  refer  to  forms 
which  are  relatively  acute;  but  there  are  many  milder  forms  which 
do  not  incapacitate  the  patient  from  work  or  compel  him  to  take 
to  his  bed.  The  extent  of  these  milder  ills  is  not  generally  appre- 
ciated. They  are  often  carefully  guarded  secrets.  The  individual 
often  knows  only  his  own  physical  troubles,  but  is  unaware  of  the 
fact  that  almost  every  person  about  him  has  such  troubles  also.  Once 
you  penetrate  beneath  conventional  acquaintance  there  will  almost 
invariably  be  found  some  functional  impairment  of  heart,  liver, 
kidneys  or  bladder;  or  dyspepsia,  gastritis,  jaundice,  gallstones, 
constipation,  diarrhea;  or  insomnia,  neurasthenia,  nervousness,  neu- 
ritis, neuralgia,  sick  headache;  or  tonsilitis,  bronchitis,  hay  fever, 
catarrh,  grip,  colds,  sore  throat;  or  rupture,  hernia,  phlebitis,  skin 
eruption;  or  rheumatism,  lumbago,  gout,  obesity;  or  decayed  teeth, 
baldness,  deafness,  eye  ailment,  spinal  curvature,  lameness,  broken 
bones,  dislocations,  sprains,  bruises,  cuts,  burns,  or  other  "  troubles." 

o  "  Eleventh  Annual  Report  of  tlie  Department  of  Inspection  of  Indiana,  1907," 
Exhibit  C,  pp.  166-198. 


KEPORT   ON    NATIONAL  VITALITY.  39 

These  so-called  "  minor  ailments  "  will  undoubtedly  in  the  next  few 
years  receive  much  more  attention  than  now.  Until  recently  the 
physician  has  been  accustomed  to  treat  only  acute  diseases,  but  as 
preventive  medicine  gradually  replaces  curative  medicine  the  physi- 
cian will  be  more  called  upon  to  treat  minor  ailments.  These  are 
generally  the  first  warnings  of  more  serious  troubles.  If  what  seem 
to  be  "  mere  colds  "  were  less  commonly  neglected,  tuberculosis  would 
more  often  be  caught  in  its  incipiency,  and  pneumonia  and  diphtheria 
would  often  be  prevented. 

From  the  "  common  colds  "  also  tonsilitis  and  abscess  of  the  ear  can  and  do 
come,  purulent  inflammations  of  tlie  pneumatic  and  venous  cavities  of  the  face 
and  skull,  and  meningitis  and  cerebral  abscess — all  of  which  destroy  many 
lives  annually ;  or  the  lives  may  be  saved  by  a  surgical  operation  after  a  serious 
and  prolonged  illness.  Tonsilitis,  in  turn,  in  addition  to  lighting  up  furious 
inflammations  in  its  own  immediate  vicinity,  can  be  held  responsible  in  a  cer- 
tain number  of  cases  for  serious  diseases  at  a  distance  from  its  own  site.  These 
are  septic  arthritis  (inflammation  of  joints),  septic  peritonitis,  appendicitis, 
endocarditis  (vahular  disease  of  the  heart) — severe  and  frequently  fatal  dis- 
eases. Gastritis  or  gastroenteritis,  sick  headache,  jaundice,  lumbago,  are  not 
usually  of  serious  import,  but  sometimes  are  the  signs  that  point  to  an  under- 
lying cause  (alcoholism,  overeating,  chronic  protein  intoxication,  worry — busi- 
ness or  domestic — sedentary  life,  etc.)  w^hich  will  lead  later  to  arteriosclerosis, 
chronic  nephritis,  toxic  amblyopia  (optic  nerve  blindness),  cirrhosis  of  the  liver, 
cerebral  hemori-hage  or  valvular  disease  of  the  heart.o 

If  the  first  twinges  of  rheumatic  pains  were  heeded,  gout  and  the 
dreaded  arthritis  deformans  would  lose  most  of  their  terrors.  We 
could  then  arrest  a  great  majority  of  serious  affections  at  the  very 
gateway.  It  can  hardly  be  doubted  that  even  such  diseases  as  cancer, 
whose  causation  is  not  yet  understood,  gain  a  foothold  through  low- 
ered vital  resistance,  manifesting  itself  at  the  first  in  minor  ailments 
of  some  kind. 

The  American  neurasthenia,  widespread  and  subtle,  has  its  grip  on 
thousands  of  men  and  women,  driving  them  from  home  and  offices 
annually  to  sanitaria  or  various  health  resorts,  and  so  breaking  down 
their  average  vitality  as  to  render  them  much  more  liable  to  serious 
sickness  and  death.  -^ 

This,  the  most  widely  prevalent  of  all  nervous  disorders  in  this 
country,  seems  to  be  on  the  increase.  It  is  very  commonly  found 
among  persons  who  take  no  reasonable  recreation — many  business 
men,  among  others — and  the  loss  of  time  and  incapacitation  for  work 
are  very  great,  often  weeks  and  months  at  a  time. 

As  to  the  extent  to  which  minor  ailments  exist,  no  statistics  are 
available.  Doctor  Castle,  of  Cincinnati,  estimates,  from  an  experi- 
ence of  many  years  in  the  medical  supervision  of  institution  em- 
ployees and  general  practice,  that  there  is  an  average  of  at  least  three 
days'  time  lost  annually  for  each  person  in  the  population  because  of 
such  minor  ailments.  Similarly,  Dr.  J.  F.  Morse,  of  the  Battle  Creek 
Sanitarium,  who  has  had  a  long  experience  in  dealing  with  a  large 
number  of  cases,  estimates  that  the  average  "  well  man  "  loses  on  an 
average  five  days  a  year  from  work  on  account  of  headaches,  tooth- 
aches, "  colds,"  and  similar  minor  ailments  which  do  not  come  under 
the  head  of  any  of  the  diseases  reported. 

<^  Letter  from  Dr.  Chas.  H.  Castle. 
84369— No.  30—09- 4 


40  REPOET   ON   NATIONAL  VITALITY. 

Section  2. — PreventaMUty  of  minor  ailments. 

That  almost  all  minor  ailments  can  be  avoided  is  scarcely  to  be 
doubted.  Doctor  Gulick  is  "  inclined  to  believe  that  something  like 
nine-tenths  of  all  the  minor  ailments  that  we  have,  and  which  consti- 
tute the  chief  source  of  decreasing  our  daily  efficiency,  could  be 
removed  by  careful  attention."  "  With  the  removal  of  nine-tenths  of 
our  disabilities  and  the  conservation  and  further  development  of  our 
natural  powers,"  he  adds,  "  the  average  person  can  increase  his  effi- 
ciency 100  per  cent,  that  is,  he  can  be  twice  as  effective.  This  does 
not  refer  to  doing  merely  or  mainly  twice  as  much  work,  of  course, 
but  by  making  less  mistakes,  and  by  working  at  a  higher  degree  of 
speed  when  he  does  work.  By  working  under  conditions  so  that  the 
work  does  not  need  to  be  repeated,  the  whole  total  will  be  much 
greater — I  think  not  too  much  to  say  twice  as  great — as  under  ordi- 
nary conditions." 

Minor  ailments  are  preventable  by  leading  a  reasonably  hygienic 
life  and  by  revising  the  modern  gospel  of  "  hustle  " — which  latter 
usually  means  crude,  imperfect,  and  slovenly  work,  whether  mental 
or  manual.  The  prevention  of  these  diseases  would  "  cost  "  nothing — 
for  it  costs  nothing  to  stay  well. 

If,  again,  we  consider  the  experience  of  those  who  have  made  a 
serious  attempt  to  avoid  minor  ailments,  their  preventability  becomes 
clear.  Personally,  I  have  known  of  scores  of  cases  in  which  the  tend- 
ency to  catch  cold  has  been  almost  completely  overcome.  In  one 
case  a  physician,  who  as  a  boy  had  suffered  from  continual  colds  and 
hay  fever,  succeeded,  through  the  simplification  and  control  of  his 
diet,  in  attaining  almost  complete  emancipation,  which  has  lasted  over 
forty  years.  Another  physician  reports  that  for  ten  years,  during 
which  time  he  has  taken  special  means  to  produce  complete  evacua- 
tion, he  has  not  caught  a  single  cold.  A  large  number  of  cases  ob- 
served are  of  persons,  physicians  as  well  as  laymen,  who  have  taken 
the  outdoor  cure  for  tuberculosis  or  nervous  prostration.  These 
persons  not  only  succeeded  in  combating  these  serious  troubles,  but 
in  completely  freeing  themselves  from  liability  to  colds.  Evidently, 
if  the  outdoor  life  had  been  adopted  simply  as  a  preventive  of  colds, 
it  would  have  prevented  originally,  as  it  cured  subsequently,  their 
more  serious  disorders. 

Chapter  V. — Prevalence  of  undue  fatigue. 

Section  1. — Strength,  endurance,  and  fatigue. 

When  a  person  is  free  from  all  specific  ailments,  both  serious  and 
minor,  he  usually  calls  himself  "  well."  There  is,  however,  a  vast 
difference  between  such  a  "  well "  man  and  one  in  ideally  robust 
health.  The  difference  is  one  of  endurance  or  susceptibility  to 
fatigue.  Many  "  well "  men  can  not  run  a  block  for  a  street  car  or 
climb  more  than  one  flight  of  stairs  without  feeling  completely  tired 
out,  while  another  "  well  "  man  will  run  25  miles  or  climb  the  Matter- 
horn  from  pure  love  of  sport.  The  Swiss  guides,  throughout  the 
summer  season  day  after  day,  spend  their  entire  time  in  climbing. 
A  Chinese  cooly  will  run  for  hours  at  a  stretch.  That  the  world 
regards  such  performances  as  "  marvelous  feats  of  endurance  "  only 


REPORT    ON    NATIONAL  VITALITY.  41 

shows  how  niarveloush^  out  of  training  the  world  as  a  AThole  really 
is.  In  mental  work  some  persons  are  unable  to  apply  themselves  more 
than  an  hour  at  a  time,  while  others,  like  Humboldt  or  Mommsen,  can 
work  almost  continuously  through  fifteen  hours  of  the  day. 

As  Mosso  °  and  others  have  proved,  muscular  fatigue  is  a  chemical 
effect,  due  to  the  circulation  of  "  fatigue  poisons  "  in  the  blood.  This 
has  been  strikingly  shown  by  experiments  by  Weishardt  and  others 
on  dogs;  when  blood  is  transfused  from  an  exhausted  dog  to  a 
"  frisky "  one,  the  latter  immediately  wilts  and  becomes  fatigued 
like  the  former,  although  he  has  not  exerted  himself  in  the  least.  In 
order  to  reduce  fatigue,  therefore,  we  should  keep  down  fatigue 
poisons.  It  is  not  unlikely  that  almost  all  poisons  produce  fatigue, 
whether  the  poisons  come  from  infections,  from  drugs,  from  impure 
or  excessive  food,  from  bad  air,  or  from  exertion. 

It  should  be  noted  that  endurance  is  a  quality  quite  distinct  from 
strength.^  Strength  is  measured  by  the  utmost  force  a  muscle  can 
exert  once;  endurance  by  the  number  of  times  it  can  repeat  an  ex- 
ertion requiring  a  specified  fraction  of  available  strength  at  the  start. 
Thus,  if  each  one  of  two  men  is  barely  able  to  lift  a  dumb-bell  weigh- 
ing 100  pounds,  their  strengths  are  equal,  but  if  one  of  them  can  raise 
a  dumb-bell  weighing  50  pounds  20  times,  while  the  other  can  raise  it 
40  times,  the  latter  may  be  said  to  have  double  the  endurance  of  the 
former.  Another  mode  of  expressing  the  same  thought  is  that  endur- 
ance is  measured  by  the  slowness  with  which  strength  decreases 
through  exertion. 

Section  2. — Alcohol  and  fatigue. 

Of  all  poisons  in  ordinary  use,  alcohol  and  tobacco  are  the  most 
common.  That  alcohol  increases  fatigue  is  now  commonly  recognized 
by  athletes.  "Alcohol  gives  no  persistent  increase  of  muscular  power. 
It  is  well  understood  by  all  who  control  large  bodies  of  men  engaged 
in  physical  labor  that  alcohol  and  effective  work  are  incompatible."  <^ 

One  of  the  most  interesting  features  of  the  cycling  sport,  when  long 
tours  were  the  fashion  a  few  years  ago,  was  the  fact  that  the  wayside 
seller  of  drinks  found  himself  forced  to  supply  chiefly  "  temperance 
drinks."  The  cyclists  discovered  that  they  could  not  make  their  "  cen- 
tury runs  "  on  alcoholic  beverages.  Two  friends  report  that  they 
stopped  for  refreshments  and  drank  beer.  Resuming  their  ride  they 
found  it  hard  to  propel  the  machine,  and  both  imagined  some  obstruc- 
tion had  lodged  in  the  gears.  Only  after  having  dismounted  and  sat- 
isfied themselves  to  the  contrary  did  they  come  to  the  conclusion, 
whether  rightly  or  wrongly,  that  the  resistance  was  in  their  own  legs 
and  was  due  to  the  beer. 

Careful  experiments  with  alcohol  in  relation  to  fatigue  have  been 
reported  by  Eivers,^  who  shows  that  alcohol  diminishes  the  capacity 

«  See  "Fatigue,"  English  translation.    New  York  (Putnam),  1904. 

^  See  Irving  Fisher  :  "  The  Effect  of  Diet  on  Endurance."  ( Publications  of  Yale 
University,  Transactions  of  the  Connecticut  Academy  of  Arts  and  Sciences; 
New  Haven,  1906,  p.  1.) 

"  "  The  Liquor  Problem,  a  summary,"  report  of  subcommittee  of  committee  of 
fifty  on  physiological  aspects  of  the  liquor  problem.  New  York  (Houghton- 
Mifflin),  1905. 

*  W.  H.  R.  Rivers:  "Influence  of  Alcohol  on  Fatigue,  etc."  London  (Edward 
Arnold),  1908,  pp.  89-90. 


42  EEPOKT   ON   NATIONAL   VITALITY. 

for  exertion.  Experiments  carried  on  by  Professor  Aschaffenburg 
with  four  typesetters,  all  users  of  alcohol,  showed  that  on  days  when 
Greek  wine,  containing  18  per  cent  of  alcohol,  was  given  the  men 
there  was  considerable  diminution  of  the  capacity  for  work.  On 
the  alcohol  days  two  of  the  men  did  decidedly  less  work,  while  the 
work  of  the  remaining  two  was  marked  by  great  irregularity. 

The  injury  from,  alcohol  is  mitigated,  but  not  excluded,  through 
combination  with,  sugar,  malt,  and  other  beneficial  ingredients,  as 
in  beer. 

Section  3.  —Tobacco  and  fatigue. 

As  to  tobacco  it  is  a  common  observation  that  smoking  interferes 
with  one's  "  wind  "  in  running.  The  poisons  which  probably  bring 
about  this  result  include  others  than  nicotine.  Possibly  the  most 
important  poison  is  carbon  monoxide,  which  has  a  great  affinity  for 
the  iron  in  the  blood."^  When  the  smoker  "  inhales,"  this  poison, 
probably  joined  with  others,  enters  directly  into  the  blood  stream. 

In  an  experiment  carried  on  by  Doctor  Lombard,  "  smoking  was 
found  to  have  a  very  depressing  effect  upon  the  strength  of  the 
voluntary  muscular  contractions.  *  *  *  Undoubtedly  the  effect 
of  tobacco  to  lessen  the  voluntary  power  is  due  to  its  influence  upon 
the  central  nervous  system."  * 

It  is  the  testimony  of  many  users  of  tobacco  that  the  habit  of 
smoking  leads  to  nervousness  and  disinclination  to  exertion  directly 
after  smoking. 

Experimentation  has  shown  that  smoking  increases  blood  pressure. 
The  greater  resistance  to  circulation  offered  by  the  blood  is  pre- 
sumably due  to  the  excitation  caused  by  the  introduction  into  the 
blood  stream  of  foreign  matter  from  the  tobacco.  There  is  reason 
to  believe,  though  the  fact  has  not  been  established,  that  endurance 
is  lessened  by  high  blood  pressure. 

Section   4. — Diet   and-  fatigue. 

Poisons  may  also  enter  the  system  through  food.  Many  poisons 
come  from  diseased,  contaminated,  or  adulterated  foods ;  but  they  may 
also  be  due  to  excess  of  food  or  wrong  preparation  of  foods,  and  espe- 
cially to  the  decomposition  of  protein  (the  principal  ingredient  of 
white  of  egg  and  lean  meat)  in  the  colon.  The  absorption  of  such 
poisons  causes  auto-intoxication. 

It  has  long  been  known  by  physiologists  that  the  putrefaction  in 
the  intestines  is  the  putrefaction  of  protein.  But  only  recently  have 
they  raised  the  question  whether  a  reduction  of  the  protein  element 
of  food  would  be  feasible  and  whether  the  resulting  reduction  in 
putrefaction  and  auto-intoxication  might  not  be  advantageous.*' 
These  questions  are  still  under  debate,  but  the  trend  of  physiological 
opinion  is  increasingly  in  favor  of  protein  reduction.  Practically 
this  means  a  lessening  of  the  consumption  of  lean  meat  and  eggs. 

o  "  The  toxicity  of  tobacco  smoke,"  The  Lancet,  CLXXV,  1908,  p.  104. 

^Warren  P.  Lombard,  M.  D.,  "  Some  of  the  influences  which  affect  the  power 
of  voluntary  muscular  contraction."  Journal  of  Physiology,  Vol.  XIII,  1892, 
p.  48. 

"  See  C.  A.  Herter,  "  Bacterial  Infections  of  the  Digestive  Tract,"  New  York 
(Macmillan),  1907. 


EEPORT   ON    NATIONAL  VITALITY.  43 

Evidence  has  accumulated,  though  it  has  not  yet  been  put  in  proper 
experimental  form  for  absolute  proof,  that  auto-intoxication  is  not 
only  an  exceedingly  common  affection,  but  also  the  chief  cause  of 
undue  fatigue.  Most  persons  know  the  heavy  feeling  and  disinclina- 
tion to  exertion  which  generally  accompany  constipation,  and,  on 
the  other  hand,  the  relief  which  comes  with  a  complete  evacuation. 

Leaving  auto-intoxication  aside,  Professor  Chittenden  is  of  the 
opinion  that  waste  products  from  combustion  of  protein  are  probably 
responsible  for  fatigue.  Whatever  the  explanation.  Professor  Chit- 
tenden found  in  his  classical  experiment '^  with  a  squad  of  soldiers, 
(hat  strength  and  endurance  were  increased  by  a  reduction  of  the 
protein.  Thirteen  soldiers  were  placed  for  six  months  on  a  diet  con- 
taining a  much  smaller  quantity  of  protein  food  than  what  is  pre- 
scribed by  ordinary  dietary  standards  and  containing  only  one-third 
of  what  is  demanded  by  common  American  usage.  Professor  Chit- 
tenden's results  are  gaining  recognition,  but  they  will  need  to  be 
further  tested  before  any  unanimity  of  opinion  can  be  reached. 

Analysis  of  the  diet  of  several  hundred  vegetarians  shows  that  on 
the  whole  they  are  lower  in  protein  than  the  average  American. 
Comparative  experiments  on  17  vegetarians  and  25  meat  eaters  in  the 
laboratory  of  the  University  of  Brussels  have  shown  little  differences 
in  strength  between  the  two  classes,  but  a  marked  superiority  of  the 
vegetarians  in  point  of  endurance.  The  average  superiority  was  53 
per  cent.  The  vegetarians  recuperated  from  fatigue  more  quickly 
than  the  meat  eaters,^  To  what  extent,  if  at  all,  the  superiority  of 
the  vegetarians  was  due  to  vegetarianism  as  such,  and  to  what  extent 
to  the  fact  that  they  made  a  more  moderate  use  of  protein,  can  not 
be  exactly  determined,  although  the  evidence  indicates  that  the  lower 
protein  is  the  essential  factor.  The  virtues  and  drawbacks  of  vege- 
tarianism as  such  have  as  yet  received  almost  no  scientific  study." 
Professor  Chittenden  is  now  engaged  in  such  a  study. 

In  another  experiment,  comprising  49  subjects  and  contrasting 
those  on  high  and  low  protein  diets,  it  was  found  that  the  low  pro- 
tein subjects  had  greater  endurance.*^  For  instance,  the  test  of 
"deep-knee  bending"  showed  that  whereas  the  high-protein  subjects 
could  seldom  exceed  4-00  or  500  times,  the  low-protein  men  could  fre- 
quently exceed  1,000,  and  in  one  case  reached  2,400. 

The  writer  has  in  his  possession  several  hundred  unpublished  in- 
dividual records  of  men  on  a  low  and  high  protein  diet.  These,  on 
the  whole,  seem  to  show  a  considerable  superiority  in  endurance 
among  those  using  the  lesser  amounts  of  protein.  But  while  the  trend 
of  evidence  seems  at  present  to  favor  a  reduction  in  protein,  the  ques- 
tion is  not  yet  settled.^    There  exist  many  conspicuous  cases  of  high 

°  See  Russell  H.  Chittenden,  "  Physiological  Economy  in  Nutrition,"  New  York 
(Stokes),  1904,  and  "The  Nutrition  of  Man,"  New  York  (Stokes),  1907. 

^  "  Enquete  Scientifique  sur  les  Vegeteriens  de  Bruxelles,"  par  Mile,  le  Dr.  J. 
loteyko  and  Mile.  Varia  Kipiani,  Bruxelles  (Lemartin),  1907.  For  English 
abstract  see  "  Diet  and  Endurance  at  Brussels,"  Science,  Vol.  XXVI,  1907  pp 
561-563. 

"An  exception  is  Caspari,  "  Physiologische  Studien  iiber  Vegetarismus," 
Bonn  (Hager),  1905;  see  also  Gautier,  "Diet  and  Dietetics,"  English  transla- 
tion, London,  1906. 

*  Irving  Fisher,  "  Influence  of  flesh  eating  on  endurance,"  Yale  Medical  Jour- 
nal, March,  1907. 

«  See,  for  example,  Prof.  F.  G.  Benedict's  paper  on  "  The  nutritive  require- 
ments of  the  body,"  American  Journal  of  Physiology,  Vol.  XVI.  1906.  m>. 
409^37. 


44  REPOET   ON   NATIONAL  VITALITY. 

protein  and  great  endurance.     A  striking  instance  is  that  of  the 
pedestrian  Weston. 

In  an  experiment  on  nine  healthy  students,  the  writer  found  that 
thorough  mastication  seemed  to  cause  a  gradual  decrease  in  protein. 
The  significance  of  the  experiment  lay  in  the  improvement  in  physi- 
cal endurance  of  eight  of  the  men,  which  increased  over  90  per  cent 
in  five  months.  The  ninth  man — the  only  one  whose  protein  was  not 
greatly  reduced — failed  to  improve  in  endurance." 

Section  5. — Exertion  and  fatigue. 

Exertion  increases  combustion  of  oxygen,  and  the  capacity  for  ex- 
ertion is  intimately  related  to  the  completeness  of  this  combustion. 

Experiments  in  artificially  administering  oxygen  to  athletes  have 
been  made  in  England  by  Hill,  Flack,  Pombrey,  and  others.''  Fol- 
lowing these,  a  series  of  experiments  in  swimming  recently  took 
place  at  Huntington,  L.  I.  The  swimmers  to  whom  oxygen  had  been 
administered  surpassed  their  nonoxygenized  competitors  as  well  as 
their  own  previous  natural  records.  Doctor  Bising,  who  carried  on 
the  experiment,  states  that  the  effects  of  oxygen  inhalation  are  useful 
for  short  efforts  only.  At  most  the  oxygen  exercises  its  influence 
for  not  more  than  three  minutes. 

Perhaps  the  most  important  of  the  common  influences  affecting  the 
capacity  to  resist  fatigue  is  physical  exertion.  It  is  well  known  that 
a  man  "  in  training  "  has  greater  endurance  than  one  who  attempts 
exertion  without  previous  systematic  exercise  or  training.  In  general, 
it  may  be  said  that  a  person  in  the  "  pink  of  condition  "  is  fit  not 
only  for  physical  but  also  for  mental  exertion.  The  great  majority  of 
adults  are  far  from  being  "  in  condition,"  suffering  either  from  lack 
of  exercise  or  from  too  much  exercise.  The  ordinary  man  errs  either 
in  one  direction  or  the  other.  The  brain  worker  lives  too  sedentary  a 
life,  while  the  manual  worker,  through  fatigue  caused  by  lon^  hours, 
is  in  a  continual  state  of  overexertion.  Could  these  conditions  be 
remedied,  endurance,  as  measured  by  capacity  to  withstand  prolonged 
strains,  might  be  greatly  increased. 

Experiments  have  shown  that  physical  endurance  can  be  doubled 
by  dietetic  causes  alone,  or  doubled  by  exercise  alone.  By  both 
together  it  is  not  unlikely  that  it  could  be  tripled  or  quadrupled. 
But  when  it  is  said  that  the  endurance,  or  capacity  for  exertion,  of 
the  ordinary  healthy  man  could  be  thus  multiplied,  it  is  not  meant 
that  the  hours  of  his  daily  work,  or  even  his  daily  output  of  work, 
could  be  increased  in  such  a  ratio.  What  it  does  mean  is  the  removal 
of  the  fatigue  limit,  a  freer  and  more  buoyant  life,  and  a  visible 
increase  in  the  quantity  and  quality  of  work  per  hour. 

In  an  ideal  life  fatigue  would  seldom  be  experienced.  But  in 
most  lives,  unfortunately,  fatigue  is  a  daily  experience.  A  workman 
who  gives  intelligent  and  systematic  care  to  the  body  writes  that 
when  after  a  long  day's  work  the  factory  whistle  blows  at  night  he, 
unlike  his  fellows,  feels  as  fresh  as  when  he  began  work  in  the  morn- 
ing.    Workmen  can  by  such  self-care  mitigate  some  of  the  evils  of 

«  Irving  Fisher,  "  Effect  of  diet  on  endurance,"  loc.  cit. 

6  British  Medical  Journal,  1908,  August  22,  p.  499;  also  August  29,  p.  578, 
Journal  of  Physiology,  1908,  XXXVII,  77-112. 


REPORT    ON    NATIONAL   VITALITY.  45 

"  the  long  day."  But  they  are  amply  justified,  both  in  the  interest 
of  their  own  and  of  national  efficiency,  in  continuing  their  efforts 
toward  a  shortening  of  the  work  day. 

Section  6. — The  working  day. 

The  present  working  day  is  a  striking  example  of  the  failure  to 
conserve  national  vitality.  In  order  to  keep  labor  power  unimpaired, 
the  working  day  should  be  physiological — i.  e.,  it  should  be  such  as 
would  enable  the  average  individual  to  completely  recuperate  over 
night.  Otherwise,  instead  of  a  simple  daily  cycle,  there  is  a  pro- 
gressive deterioration.  A  reduction  in  the  length  of  the  work  day 
would  be  a  chief  means  of  improving  the  vitality  of  workmen,  as  well 
as  the  worth  of  life  to  them. 

The  fatigue  of  workmen  is  largely  traceable  to  their  long  work 
day  and  serves  to  start  a  vicious  circle.  Fatigue  puts  the  workman 
in  an  abnormal  frame  of  mind.  He  seeks  to  deaden  his  fatigue  by 
alcohol,  tobacco,  exciting  amusements,  and  excessas  of  various  kinds. 
The  momentary  relief  which  he  thereby  obtains  is  purchased  at  the 
expense  of  an  increasing  susceptibility  to  fatigue,  resulting  sooner 
or  later  in  complete  depletion  of  his  vital  energies  and  in  the  con- 
traction of  tuberculosis  or  other  fatal  disease.  The  decrease  in  the 
length  of  the  working  day  has  not  diminished  the  total  output. 

An  instance  in  which  the  eight-hour  day  superseded  the  nine-hour 
day  with  entire  success  is  the  case  of  the  Salford  Iron  Works,  of  Mather 
&  Piatt,  at  Manchester,  England,  which  changed  to  the  eight-hour 
day  in  1893.  As  the  firm's  products  were  subject  to  keen  competition 
in  both  home  and  foreign  markets,  it  was  obliged  to  look  carefully 
after  the  labor  cost,  and  its  conclusion  that  such  cost  did  not  increase 
in  consequence  of  the  reduction  in  working  hours  was  reached  after 
extremely  accurate  comparisons  by  accountants,  who  of  course  took 
into  consideration  the  saving  in  consumables,  wear  and  tear,  fuel,  etc. 
The  Bureau  of  Labor  inquired  of  Messrs.  Mather  &  Piatt  if  they  were 
still  on  the  eight-hour  basis,  and  received  a  reply  dated  May,  24, 1904, 
in  which  they  stated  that — 

our  experience  since  the  first  year  in  which  it  (the  eight-hour  system)  was  tried 
has  fully  borne  out  the  conclusions  then  arrived  at,  and  we  are  fully  satisfied 
that  as  regards  the  comparison  between  eight  and  nine  hours  per  day  the  bal- 
ance of  advantages  is  in  favor  of  the  shorter  period.** 

In  1894  the  hours  of  labor  of  about  43,000  workmen  in  British  government 
factories  and  workshops  were  reduced  to  forty-eight  per  week.  Of  this  number, 
18,600  received  a  reduction  of  five  and  three-fourths  hours  a  week,  and  24,300 
had  their  time  reduced  two  and  one-half  hours  a  week.  With  no  change  in 
piece  rates  the  workmen  were  able  to  earn  as  much  as  formerly.  Day  workers 
received  an  increased  hourly  rate  of  pay  to  make  their  earnings  per  week  of 
forty-eight  hours  equal  to  those  per  week  of  fifty-four  hours.  It  was  not  found 
necessary  to  increase  the  number  of  day  workers.* 

In  1899  the  owners  of  the  great  Zeiss  optical  goods  factory  at  Jena, 
Germany,  introduced  the  eight-hour  day  and  then  made  careful  rec- 
ords of  the  results.  In  1903  it  was  announced  that  although  the 
aggregate  number  of  hours  worked  had  decreased  15  per  cent  the  out- 
put per  hour  had  increased  16.2  per  cent." 

"  New  York  Labor  Bulletin  No.  25,  June,  1905,  p.  240. 

*  Board  of  Trade  Labor  Gazette,  July,  1905,  reported  in  New  York  Labor 
Bulletin  No.  28,  March,  1906. 

"  New  York  Labor  Bulletin,  No.  25,  June,  1905,  p.  240. 


46  EEPOKT   OlSr    NATIONAL  VITALITY. 

At  Liege  it  was  found  in  a  sulphuric  acid  establishment  similar  to 
a  foundry  "  that  shortening  the  working  day  from  eleven  hours  to  ten, 
from  ten  to  nine,  and  so  on  gradually  down  to  seven  and  one-half, 
resulted,  in  each  case,  in  an  increase  of  the  output. 

The  Solvay  Process  Company,  of  Syracuse,  installed  in  1892  a 
system  of  three  eight-hour  shifts  in  place  of  the  two  previous  shifts 
of  eleven  and  thirteen  hours,  respectively.  It  was  stated  by  the 
assistant  general  manager  in  1905  that  the  change  had  considerably 
lessened  the  wear  and  tear  on  the  men,  and  that  they  could  be  called 
on  to  do  their  work  at  their  highest  state  of  efficiency,  which  had  not 
been  possible  on  the  two-shift  basis.  President  Hazard  of  the  com- 
pany writes : 

In  general,  I  can  say  that  tlie  results  of  the  change  from  a  twelve-hour  shift 
to  an  eight-hour  shift  were  very  satisfactory  and  have  continued  to  be  so. 
While  the  immediate  result  was  to  considerably  increase  the  cost  per  unit  of  prod- 
uct, the  efficiency  of  the  men  gradually  increased,  so  that  at  the  end  of  about 
one  year  the  first  increase  has  been  overcome  and  the  cost  per  unit  of  product 
fell  to  a  point  even  lower  than  had  been  obtained  under  the  twelve-hour  shift, 
and  further  the  time  consumed  per  unit  of  product  has  since  been  so  reduced 
that  we  are  today  and  for  some  time  have  been  operating  with  a  smaller 
number  of  hours  per  unit  of  product  than  we  had  under  the  twelve-hour  shift. 

Further  proof  of  the  benefits  of  the  change  to  the  three-shift  day 
is  furnished  by  the  records  of  the  Solvay  Mutual  Benefit  Association 
for  1891  and  1904.  The  days  lost  per  man  by  sickness  each  year  fell 
from  seven  and  one-half  days  in  1891  to  five  and  one-half  days  in 
1904. 

It  is  not  maintained  that  in  all  cases  productivity  will  be  as  great 
in  eight  hours  as  in  nine.  Cases  to  the  contrary  could  also  be  cited. 
The  point  to  be  insisted  upon  is  not  that  it  is  profitable  to  an  em- 
ployer to  make  the  work  day  shorter,  for  often  it  is  not,  but  to  show 
that  it  is  profitable  to  the  nation  and  the  race.  Continual  fatigue  is 
inimical  to  national  vitality,  and  however  it  may  affect  the  commer- 
cial profits  of  the  individual  it  will  in  the  end  dejolete  the  vital 
resources  on  which  national  efficiency  depends. 

In  the  interests  of  this  efficiency,  a  longer  time  at  noon  for  lunch 
is  usually  necessary.  The  present  economy  of  lunch  time  is  short- 
sighted, tends  to  food  bolting,  indigestion,  a  drowsy  and  tired  after- 
noon, and  inferior  work.     This  has  been  shown  by  actual  experience.* 

The  accident  bulletins  of  the  Interstate  Commerce  Commission 
contain  frequent  records  of  disasters  caused  by  the  long  hours  of  rail- 
way employees.  In  a  recent  bulletin,  No.  27,  two  collisions  are  at- 
tributed to  the  mistakes  of  employees  who  have  been  on  duty  much 
longer  than  the  instinct  of  safety  should  allow.  Collision  No.  3,*' 
which  killed  2  and  injured  13,  was  due  to  the  mistake  of  a  station 
operator  who  had  been  on  duty  from  7  a.  m.  to  3.30  p.  m.  and  who 
had  returned  to  duty  at  8  p.  m.  The  collision  took  place  at  12.30 
a.  m.  the  next  morning. 

"  See  L.  G.  Fromont,  "  Une  Experience  Industrielle  de  Reduction  de  la  Journel 
de  Travail,"  Brussels,  Solvay  Institute,  1906. 

*  See  especially  description  of  a  French  experiment  cited  by  Hubert  Higgins 
in  "I-Iunianiculture,"  New  York  (Stokes),  1906. 

"Accident  Bulletin  No.  27,  January  to  March,  1908. 


REPORT   ON    NATIONAL  VITALITY.  47 

Section  7. — Importance  of  preventing  undue  fatigue. 

The  economic  waste  from  undue  fatigue  is  probably  much  greater 
than  the  Avaste  from  serious  illness.  We  have  seen  that  the  average 
serious  illness  per  capita  is  usually  about  two  weeks  each  year.  This 
is  about  4  per  cent  of  the  year.  Expressed  differently,  about  4  per 
cent  of  the  population  is  constantly  sick. 

On  the  other  hand,  the  number  that  suffer  partial  disability 
through  undue  fatigue  certainly  constitute  the  great  majority  of  the 
population.  No  observer  can  fail  to  conclude  that  this  is  true  of  the 
American  working,  business,  and  professional  classes,  and  the  latest 
word  among  the  students  of  school  hygiene  is  that  it  is  true  to  a 
large  extent  even  among  children.  If  therefore  Ave  assume  that  only 
50  per  cent  of  the  population  is  suffering  some  impairment  of  its 
best  powers  through  undue  fatigue,  we  are  on  safe  ground.  The  ex- 
tent to  which  the  power  of  this  supposed  50  j)er  cent  of  the  popula- 
tion is  impaired  must  certainly  exceed  10  per  cent.  "When  we  consider 
that  young  men,  supposed  to  be  perfectly  well,  have  the  enormous 
room  for  improvement  indicated  in  this  chapter,  and  when  we  con- 
sider the  gratifying  results  of  experiments  with  a  shorter  work  day  it 
will  be  seen  that  the  true  impairment  is  probably  several  times  10  per 
cent.  Yet  if  only  50  per  cent  of  the  population  are  suffering  an  im- 
pairment equal  to  only  10  per  cent  of  its  working  powers,  the  result 
is  equivalent  to  5  per  cent  of  the  population  suffering  total  impair- 
ment which  is  more  than  the  4  per  cent  impairment  from  serious 
illness. 

The  relatively  slight  impairment  of  efficiency  due  to  overfatigue 
leads  to  more  serious  impairment.  Just  as  minor  ailments  prove  to 
have  an  unsuspected  importance  when  considered  as  gateways  to 
serious  illness,  so  the  inefficiency  from  fatigue  is  vested  with  great 
significance  as  the  first  step  toward  minor  ailments.  Obviously  if 
overfatigue  could  be  reduced  to  a  minimum,  this  reduction  would 
carry  with  it  the  prevention  of  the  major  part  of  minor  ailments, 
which  in  turn  would  lead  to  a  great  reduction  in  more  serious  illness, 
and  this  finally  would  lead  to  a  great  reduction  in  mortality.  A 
typical  succession  of  events  is  first  fatigue,  then  colds,  then  tubercu- 
losis, then  death.  Prevention,  to  be  effective,  must  begin  at  the 
beginning. 

But  prevention  is  merely  the  first  step  in  increasing  the  breadth  of 
life.  Life  is  to  be  broadened  not  only  negatively  by  diminishing  those 
disabilities  which  now  narrow  it,  but  also  positively  by  increasing  the 
cultivation  of  vitality.  Here  we  leave  the  realm  of  medicine  and 
enter  the  realm  of  physical  training.  The  first  and  lowest  step  is 
gymnastics.  This  is  valuable — far  more  so  than  the  ordinary  seden- 
tary man  who  neglects  it  realizes — but  it  is  after  all  a  kind  of  medicine 
not  altogether  pleasant  to  take  and  far  less  valuable  to  him  who  takes 
it  than  are  athletic  sports,  which  constitute  the  next  highest  stage. 
Beyond  athletic  sports  in  turn  comes  mental,  moral,  and  spiritual 
culture,  the  highest  product  of  health  cultivation.  It  is  an  encour- 
aging sign  of  the  times  that  the  ecclesiastical  view  of  the  Middle  Ages, 
which  associated  saintliness  with  sickliness,  has  giA^en  way  to  modern 
"muscular  Christianity,"  typified  in  Young  Men's  Christian  Associ- 
ations with  their  gymnastics  and  athletics.    This  is  but  one  evidence 


48  REPOET   ON    NATIONAL  VITALITY. 

of  the  tendency  toward  the  "religion  of  healthymindedness "  de- 
scribed by  Professor  James.  Epictetus  taught  that  no  one  could  be 
the  highest  type  of  philosopher  unless  in  exuberant  health.  Expres- 
sions of  Emerson's  and  Walt  Whitman's  show  how  much  their  spirit- 
ual exaltation  was  bound  up  with  health  ideals.  "  Give  me  health  and 
a  day,"  said  Emerson,  "  and, I  will  make  the  pomp  of  emperors  ridicu- 
lous." It  is  only  when  these  health  ideals  take  a  deep  hold  that  a 
nation  can  achieve  its  highest  state  of  development.  Any  country 
which  adopts  such  ideals  as  an  integral  part  of  its  practical  life 
philosophy  may  be  expected  to  reach  or  even  excel  the  development 
of  the  health-loving  Greeks. 

The  means  of  securing  both  the  negative  prevention  of  invalidity 
and  the  positive  accumulation  of  vitality  will  form  the  subject  of 
Part  III. 


Part   III.— METHODS   OF   CONSERVING  LIFE. 

Chapter  VI. — Conservation  through  heredity. 
Section  1. — Heredity  and  environment. 

That  the  waste  of  life  through  preventable  disease  and  death  is 
enormous  appears  clearly  from  the  facts  already  cited.  The  practical 
problem  is  this :  If  such  waste  is  really  preventable,  what  are  the  con- 
ditions necessary  to  make  prevention  an  accomplished  fact?  There 
are  two  main  conditions.  First,  a  general  desire  for  improvement; 
second,  a  general  knowledge  of  how  to  secure  that  improvement. 

Once  the  general  public  recognizes  the  needless  waste  of  vitality, 
it  will  not  be  content  until  that  waste  has  been  eliminated.  To  such 
an  awakening  the  American  instinct  of  economy  is  in  itself  a  power- 
ful spur.  Practical  men  are  coming  to  consider  it  "  good  business  " 
to  take  some  care  of  their  own  vital  resources.  As  this  view  gains 
ground,  habits  and  fashions  will  adapt  themselves  to  the  change. 
The  folly  of  the  man  who  loses  his  health  in  the  pursuit  of  wealth, 
and  then  for  the  rest  of  his  days  spends  his  wealth  to  win  back  health, 
is  beginning  to  be  appreciated. 

Human  vitality  depends  upon  two  primary  conditions,  heredity 
and  hj^giene,  or  conditions  preceding  birth  and  conditions  during  life. 
In  other  words,  vitality  is  partly  inherited  and  partly  acquired. 

It  is  well  known  that  cultivated  plants  and  animals  have  been 
greatly  changed  and  developed  by  breeding.  "  The  original  ajiple, 
as  offered  by  nature  to  mankind,  was  the  small,  sour,  bitter  crab  of 
the  forest,  unpleasant,  indigestible,  innutritions.  *  *  *  jj^  1710 
Doctor  Davenant,  a  writer  on  political  economy,  estimated  that  the 
average  weight  of  dressed  cattle  did  not  exceed  370  pounds.  *  *  * 
In  1846  McCullock  stated  that  '  at  present  the  average  weight  of 
cattle  is  estimated  at  or  about  800  pounds.' "« 

Human  heredity  is  now  dependent  on  haphazard  selection.  Little 
attention  is  paid  by  those  who  contemplate  marriage  to  the  question 
of  how  much  stamina  will  be  transmitted  to  the  next  generation.  The 
story  was  told  of  a  famous  dog  fancier  who,  when  asked  why  he  paid 
so  much  attention  to  his  dogs  but  delegated  the  care  of  his  children  to 
nurses,  replied :  "  My  dogs  have  a  pedigree."  Human  pedigrees,  no 
less  than  canine,  rest  on  a  physical  basis ;  yet  genealogical  records  of 
human  beings,  while  they  have  much  to  say  of  social  position,  have 
very  little  to  say  of  physical  capacity  or  intellectual  ability.  Those 
who,  like  Galton  and  Pearson,  believe  in  a  science  of  eugenics,  hope 
that  the  day  will  come  when  pride  of  inheritance  will  include  as  im- 

"  See  Dr.  Edward  Jarvis,  "  Political  Economy  and  Health,"  Fifth  Report,  Mass. 
Board  of  Health,  1874,  Doctor  Jarvis  adds  that  human  life  is  as  "  expansible  " 
as  animal  life. 

49 


50  KEPORT   ON    NATIONAL  VITALITY. 

portant,  if  not  as  the  chief  items,  physical,  mental,  and  moral  stam- 
ina. A  tendency  in  this  direction  can  be  discerned.  When  the  no- 
bility commanded  the  reverence  of  all  classes,  quite  irrespective  of 
ability,  commoners,  however  well  endowed  by  nature,  could  never  ob- 
tain the  same  respect.  But  to-day  the  English  House  of  Commons  is 
more  honored  and  respected  than  the  House  of  Lords. 

Once  the  importance  of  a  physical  pedigree  comes  to  be  rated  at 
its  true  value,  a  man's  pride  in  his  own  inheritance  will  show  itself 
in  a  correlative  feeling  of  responsibility  for  future  generations.  For 
the  sake  of  children  yet  unborn,  men  and  women  will  set  for  them- 
selves physical  ideals  of  the  highest  order. 

Section  2. — Eugenics. 

The  whole  question  of  race  improvement  through  heredity  consti- 
tutes the  subject-matter  of  the  new  science  of  eugenics.  The  devotees 
of  this  science  are  at  present  engaged  in  studying  the  laws  of  heredity 
in  all  its  aspects.  The  Mendelian  doctrine  of  heredity,  with  the 
theories  of  Darwin  and  Weissmann,  are  some  of  the  topics  which  need 
to  be  studied  in  reference  to  their  practical  application. 

Until  more  results  have  been  obtained,  it  would  be  premature  to 
make  great  claims  for  the  possible  future  usefulness  of  applied 
eugenics.  A  word  may  be  said  to  prevent  misunderstanding  as  to  its 
aims.  Many  have  supposed  that  the  object  of  eugenics  was  to  bring 
about  suitable  marriages  by  compulsion  of  the  Government.  Such  a 
proposal  would  not  only  be  absolutely  impracticable,  but  would  de- 
feat the  very  ends  aimed  at.  Marriage,  above  all  human  choices, 
must,  as  a  rule,  be  left  to  the  individual,  guided  by  his  ideals  alone. 
By  the  change  of  these  ideals  alone  can  the  character  of  marriages 
be  influenced.  Sir  Francis  Galton,  the  founder  of  the  science  of 
eugenics,  expects  intelligent  public  opinion  to  be  the  chief  guide  in 
marriage.  Just  as  the  union  of  brother  and  sister  is  tabooed,  and 
the  marriage  of  even  first  cousins'^  is  eyed  askance — whether  justly  or 
not  does  not  matter — so,  if  the  aims  of  eugenists  are  carried  out,  an 
obviously  unhygienic  marriage  will  be  frowned  upon.  It  was  some- 
what in  this  way  that  the  ancient  Sparta  raised  its  vitality  to  a  high 
point  of  physical  excellence. 

Galton  has  pointed  out  ^  that  present  restrictive  rules  of  marriage 
selection  are  endured  without  any  sense  of  loss  of  privilege  or  free- 
dom. For  example,  members  of  the  European  nobility  are,  in  their 
marriage  choice,  restricted  almost  wholly  to  fellow-aristocrats;  yet 
so  much  has  this  restriction  become  a  part  of  their  ideal  and  creed 
that  the  narrowness  of  the  range  of  choice  is  not  usually  realized. 

Even  granting  that  some  marriages  are  studiously  calculated  to 
win  money  or  title,  a  much  stronger  or  more  pervasive,  although 
unconscious,  influence  is  exerted  by  the  ideals  which  young  men  and 
women  at  marriageable  age  have  formed  of  what  their  compan- 
ions for  life  should  be.     Nothing  is  more  certain  than  that  if  from 

°'  In  at  least  20  States  the  marriage  of  first  cousins  is  forbidden  by  law.  An 
excellent  discussion  of  this  subject  is  contained  in  "  Consanguineous  Marriages 
in  the  American  Population,"  by  G.  B.  L.  Arner,  Ph.  D.,  Nevf  York  (Longmans), 
1908. 

'"'Sociological  Papers,"  London  (Macmillan),  1906,  Vol.  II,  p.  12. 


REPORT   ON    NATIONAL  VITALITY.  51 

childhood  they  were  trained  to  regard  vitality  as  the  first  essential  in 
an  ideal  man  or  woman,  this  would  influence  their  personal  fancy. 
Health,  beauty,  and  vitality  are  natural  objects  of  admiration  and 
love.  Titles,  wealth,  and  other  extraneous  attractions  are  not.  To 
lessen  the  public  esteem  for  these,  and  to  increase  the  esteem  for 
natural  human  merit,  will  tend  to  increase  not  only  the  number  of 
healthy  marriages,  but  the  importance  of  the  role  played  by  normal 
love.  If,  therefore,  eugenic  ideals  ever  hold  sway,  love  marriages  will 
not  only  continue  to  exist,  but  will  become  more  frequent.  Love  is  a 
primal  and  natural  instinct,  and  the  more  natural  men  and  women 
are,  and  the  more  highl}^  they  esteem  natural  vitality,  the  more  will 
they  be  guided  by  mutual  attraction. 

If  a  considerable  percentage  of  the  population  once  shall  come  to 
regard  vitality  as  an  essential  endowment,  the  effect  on  mating  will 
be  felt  in  two  ways:  First,  a  larger  percentage  of  healthy  persons 
will  marry,  leaving  a  larger  percentage  of  unhealthy  persons  single ; 
second,  healthy  persons  will  mate  with  each  other,  and  unhealthy 
persons,  in  so  far  as  they  marry  at  all,  will  do  so  among  themselves. 
Of  mixed  matings  there  will  be  a  smaller  number.  Both  of  these 
results  will  tend  gradually  toward  the  improvement  of  the  race. 
That  the  first — the  increased  proportion  of  marriages  among  the 
healthy — will  do  so,  is  obvious.  The  second — the  marriage  of  like 
with  like  in  respect  to  health — Avould,  it  seems  probable,  operate  to 
increase  the  number  of  progeny  of  healthy  couples  and  decrease  that 
of  the  unhealthy,  especially  after  the  first  generation. 

Since  athletics  have  come  into  vogue  it  is  well  known  that  the 
athletic  ideal  has  led  to  athletic  mating.  The  tendency  of  the  present 
devotion  to  athletics  must  be  to  elevate  the  respect  for  physical 
prowess.  The  high  esteem  entertained  in  Japan  for  physical  train- 
ing and  for  hygiene  as  a  guarantee  of  the  fighting  power  of  the 
country,  constitutes  an  object  lesson,  if  not  a  warning,  to  Americans 
who  wish  their  country  to  be  the  peer  of  the  best.  It  would  be  folly, 
of  course,  to  expect  any  change  in  ideals  so  complete  that  there  would 
not  be  numerous  exceptions  to  hygienic  mating,  but,  once  the  bulk  of 
mankind  are  guided  by  a  truer  principle  in  forming  marriages,  the 
effect  on  racial  development  will  make  itself  distinctly  felt  within  a 
generation.  As  President  Roosevelt  has  said:  "The  preservation 
of  national  vigor  should  be  a  matter  of  patriotism."  Some  persons 
would  even  make  it  a  matter  of  religion. 

Section  3. — Eugenics  and  late. 

It  is  possible,  however,  that  governmental  interference  with  the 
birth  rate  may  in  future  be  employed  to  a  limited  extent.  Two  ways 
have  been  suggested:  One  is  for  the  Government  to  give  prizes  or 
bounties  to  couples  that  conform  to  certain  specified  standards  in  the 
same  way  as  the  French  Government  has  encouraged  the  increase  of 
population  by  offering  inducements  to  couples  of  the  poorer  class 
who  raise  seven  or  more  children." 

The  second  is  to  forbid  alliances  among  criminals,  paupers,  and  the 
feeble-minded.     These  classes  fall  under  the  tutelage  of  the  State, 

« In  1889,  fathers  of  seven  children  were  made  exempt  from  payment  of  the 
personal  property  tax.  This  exemption  was  in  1890  limited  to  fathers  who  paid 
taxes  of  not  over  10  francs  each. 


52  EEPOET    ON    NATIONAL   VITALITY. 

and  thereby  forfeit  their  right  to  free  choice.  Already  Indiana," 
Connecticut,*  Michigan,*'  and  other  States  in  this  country,  have 
passed  laws  of  this  sort. 

Indiana  extends  the  prohibition  to  all  persons  suffering  from  trans- 
missible disease  of  any  sort.  This  prohibition  is  called  into  daily 
operation  in  that  State.  It  is  in  the  power  of  the  Indiana  state  board 
of  health  to  raise  by  degrees  the  standards  of  health  demanded  of 
those  who  desire  license  to  marry,  a  provision  that  aims  directly  at 
the  improvement  of  human  vitality  in  the  State.  Indiana  has  gone 
even  further  and  has  recently  provided^  that  confirmed  criminals, 
imbeciles,  idiots,  and  rapists,  procreation  by  whom  is  deemed  inad- 
visable by  experts,  shall  be  unsexed  (or  "  sterilized  ")  by  surgical 
operation.  Under  this  law  over  800  prisoners  have  been  sterilized  to 
date.*^ 

The  experiments  started  in  Indiana  and  other  States  will  be  inter- 
esting to  watch,  and  promise  an  improvement  over  the  conditions 
which  have  prevailed  too  often  in  the  past.  Professor  Brewer,  of 
Yale,  tells  of  a  case  in  Connecticut  some  years  ago  where  a  feeble- 
minded pauper  woman,  kept  as  a  public  ward,  was  admired  by  a 
half-witted  farmer  living  in  an  adjoining  town.  A  selectman  of 
the  town  maintaining  the  woman  "  to  get  rid  of  her  support "  en- 
couraged their  marriage.  His  short-sightedness,  even  from  the  stand- 
point of  immediate  money  economy,  to  say  nothing  of  racial  economy, 
became  apparent  when,  a  few  years  later,  she  and  her  husband  and 
three  idiotic  children  drifted  into  the  poorhouse  of  the  husband's 
town. 

That  laws  like  the  ones  discussed,  but  of  gradually  increasing 
severity,  will  become  common  in  the  future  seems  likely;  and,  as 
Professor  Lankester  has  remarked,  humanity  will  probably  submit 
in  the  future  to  communal  restriction  of  the  right  to  multiply  with  as 
good  grace  as  it  has  given  up  the  right  to  rob  and  to  rape.^ 

The  effect  of  restrictions  upon  free  right  of  marriage,  is  discussed 
by  Doctor  Hurty,  secretary  of  the  Indiana  state  board  of  health,  as 
follows : 

It  seems  most  essential  and  necessary  that  we  have  laws  for  the  prevention 
of  the  production  of  the  unfit  if  society  is  to  be  saved  from  destruction.  Modern 
hygiene,  under  which  I  include  in  this  instance  all  such  benevolent  institutions 
as  insane  asylums  and  institutions  for  the  feeble-minded,  is  extending  the  dura- 
tion of  life  of  the  dependents  and  deficients,  and  it  might  be  added  that  the 
humane  and  hygienic  care  in  the  prisons  is  extending  the  duration  of  life  of  the 
delinquents.  In  Indiana  the  life  duration  of  the  insane  has  been  extended  eight 
years  within  the  last  two  decades.  This  slight  extension  means  a  very  con- 
siderable burden  upon  the  people,  and  if  this  class  of  deficients  is  unrestricted 
we  can  readily  see  what  a  burden  time  will  place  upon  society.  The  production 
of  the  unfit  must  cease  if  charity  and  hygiene  continue.  Otherwise  it  seems 
certain  that  society  will  be  swamped. 

a  Indiana  Laws  of  1905,  chap.  126,  H.  118,  sec.  3. 

*  Connecticut  Statutes  (revision  of  1902,  sec.  1354),  forbid  the  marriage  of 
epileptics. 

0  Michigan  forbids  the  marriage  of  epileptics. 

•J  Indiana  Law  of  1907,  chap.  215,  H.  364. 

e  Letter  from  Dr.  J.  N.  Hurty. 

^  E.  R.  Lankester,  "The  Kingdom  of  Man,"  London  (Constable),  1907,  p.  41. 

The  recent  report  of  the  Royal  Commission  on  the  Care  and  Control  of  the 
Feeble  Minded  recommends  such  restriction. 


EEPORT   ON   NATIONAL  VITALITY.  53 

While  institutional  treatment  of  the  insane  is  right  and  proper 
from  a  humanitarian  point  of  view,  by  bringing  an  increase  in  the 
average  insane  lifetime  it  adds  to  the  public  burden  and  enlarges  the 
figures  of  the  living  insane.  Mr.  Sanborn  estimates  the  average 
insane  life  in  Massachusetts  at  thirteen  years,  of  which  at  least  three 
years  occur,  on  the  average,  before  hospital  treatment  is  applied. 
He  adds: 

I  suspect  we  have  come  nearer  to  statistical  accuracy  on  this  question  in 
Massachusetts  than  has  been  reached  in  any  region  of  equal  population  any- 
where. The  world  has  been  gradually  coming  round  to  the  conclusions  reached 
by  the  late  Dr.  Pliny  Earle  (of  Northampton)  and  myself,  viz,  that  the  changes 
in  the  social  and  sanitary  conditions  of  all  civilized  countries  have  increased 
the  number  (proportioned  to  population)  of  hew  cases  of  insanity,  while  the 
improved  treatment  of  patients  in  the  meantime  has  made  the  average  insane 
life  longer  than  formerly,  and  that  in  spite  of  the  well-known  increase  in  forms, 
like  paresis  and  epilepsy,  which  may  soon  end  fatally. 

Interesting  records  exist  of  two  families  of  criminals,  the  so-called 
"Jukes"  and  the  "Tribe  of  Ishmael."  From  the  one  man  who 
founded  the  "Juke"  family  came  1,200  descendants  in  seventy-five 
years;  out  of  these,  310  were  professional  paupers,  who  spent  an 
aggregate  of  two  thousand  three  hundred  years  in  poorhouses,  50 
were  prostitutes,  7  murderers,  60  habitual  thieves,  and  130  common 
criminals. 

Dugdale  "  has  estimated  that  the  "  Juke  "  family  was  an  economic 
loss  to  the  State,  measured  in  terms  of  potential  usefulness  wasted, 
costs  of  prosecution,  expenses  of  maintenance  in  jail,  hospital,  and 
asylums,  and  of  private  loss  through  thefts  and  robberies  of  $1,300,000 
in  seventy-five  years,  or  over  $1,000  for  each  member  of  the  family. 

Similarly,  the  "  Tribe  of  Ishmael,"  numbering  1,692  individuals  in 
six  generations,  has  produced  121  known  prostitutes  and  has  bred 
hundreds  of  petty  thieves,  vagrants,  and  murderers.  The  history  of 
the  tribe  is  a  swiftly  moving  picture  of  social  degeneration  and  gross 
parasitism,  extending  from  its  seventeenth-century  convict  ancestry 
to  the  present-day  horde  of  wandering  and  criminal  descendants.^ 

Had  the  original  criminals  in  the  "  Juke  "  family  and  the  "  Tribe 
of  Ishmael "  been  sterilized  under  some  law  like  that  of  Indiana,  this 
country  would  not  only  have  been  spared  a  widely  disseminated 
criminal,  epileptic,  and  immoral  strain,  but  would  have  saved  hun- 
dreds of  thousands  of  dollars  paid  out  for  criminal  suits  and  for 
institutional  care,  to  sa;^  nothing  of  the  expenses  still  to  come  from 
the  incapacity  and  criminality  of  future  generations. 

These  cases  present  only  one  side  of  the  case.  Over  against  them 
may  be  set  illustrious  families  in  which  great  intellectual  ability  and 
moral  worth  have  been  passed  on  through  many  generations.  Such  a 
one  is  the  Hohenzollern  family.  In  commenting  on  the  frequent  oc- 
currence of  persons  of  surpassing  mental  and  moral  attainments  in 
this  family.  Woods''  says :  "  It  is  particularly  suggestive  of  what  might 
be  done  with  the  human  race  were  mankind  ever  so  inclined."  A  simi- 
lar example  from  a  different  walk  in  life  is  afforded  by  the  Darwin 
family,  where  for  four  generations  in  direct  line  (Erasmus,  Charles, 

«R.  L.  Dugdale.:  "The  Jukes,"  New  York  (Putnam),  1877. 

*  Oscar  C.  McCulloch,  "  The  Tribe  of  Ishmael,"  a  study  in  social  degeneration, 
"  Report  of  Fifteenth  Annual  Conference  of  Charities  and  Corrections,  1888," 
pp.  154-159. 

"F.  A.  Woods,  "Mental  and  Moral  Heredity,"  New  York   (Holt),  p.  79. 


54  REPORT   OIT   NATIONAL  VITALITY. 

George,  Horace,  and  Francis)  as  well  as  in  collateral  lines  (e.  g., 
Francis  Gallon)  scientific  ability  of  the  first  rank  has  been  manifest.'* 

President  Roosevelt  has  pointed  out  that  "  race  suicide  "  is  a  sig-n 
and  accompaniment  of  coming  decay.  Mere  numerical  increase  is 
not  the  whole  solution,  however;  there  must  be  improvement  in 
quality  also.  A  race  that  can  not  hold  its  fiber  strong  and  true  de- 
serves to  suffer  extinction  through  race  suicide.  The  decline  of  our 
Puritan  stock,  so  well  pictured  in  the  genteel  but  worn-out  Pyncheon 
family  of  Hawthorne's  novel,  need  not  alarm  us  if  we  can  replace  it 
with  a  new  influx  from  the  West  or  from  the  vigorous  stocks  of 
Europe. 

There  is  one  problem  which  concerns  both  the  numbers  and  the 
quality  of  future  generations,  which  hitherto  has  received  practically 
no  attention  except  in  a  partial  report  upon  the  subject  in  Australia. 
This  problem  is.  What  is  now  and  will  be  the  effect  of  voluntary 
childlessness  upon  the  size  and  character  of  the  birth  rate  and  upon 
morals  ?  It  would  be  useless,  here,  however,  to  do  more  than  mention 
this  as  one  of  the  gravest  problems  in  the  world  to-day.  Ronald  M. 
Byrnes  ^  shows  that  the  fecundity  of  Yale  graduates  has  steadily 
diminished  from  5.7  for  the  graduates  of  1701-1T91  to  2.0  for  those  of 
1867-1886.  This  reduction  is  much  greater  than  the  reduction  for  the 
whole  country,  which  is  reported  by  the  census  to  be  from  5.8  in  1790 
to  4.6  in  1900.  Degenerates  have  large  families.  From  a  study  of  150 
degenerate  families,  Doctor  Tredgold  °  found  that  the  average  num- 
ber of  children  per  family  was  7.3,  while  the  normal  average  for  the 
country  at  large  (England)  is  4.  These  figures  do  not  specify  the 
frequency  of  marriage  among  degenerates  or  the  mortality.  Unless 
the  one  is  sufficiently  low  and  the  other  sufficiently  high,  there  must 
follow  deterioration.  General  reduction  of  the  birth  rate  may  end  in 
depopulation.  It  is  not  unlikely  that  this  phenomenon  will  be  the 
stimulus  needed  to  bring  about  practical  eugenic  reforms. 

What  eugenics  might  possibly  accomplish  is  indicated  by  one 
writer  in  the  following  manner :  "  How  rapidly  the  race  would  ad- 
vance if  mankind  should  resolve :  '  The  next  generation  must  be  born 
with  healthy  bodies ;  must  be  nurtured  in  healthy  physical  and  moral 
environments;  and  must  be  filled  with  the  ambition  to  again  give 
birth  to  a  still  healthier,  still  nobler,  generation.'  "  ^ 

«The  Francis  Galton  Laboratory  for  National  Eugenics,  University  of  Lon- 
don, is  soon  to  issue  a  "  Treasury  of  Human  Intieritance,"  containing  pedigrees 
illustrating  inheritance  of  various  types  of  intellectual  ability,  of  tuberculous 
stocks,  of  epilepsy,  physical  depravity,  etc. 

*  Tale  Review,  November,  1908. 

<'  W.  C.  D.  Whetham,  "  Inheritance  and  Sociology,"  the  Nineteenth  Century, 
January,  1909. 

^  Louis  R.  Ehrich,  "  Posteritism,"  an  address  delivered  at  the  dedication  ex- 
ercises of  The  Century  Chest,  Colorado  Springs,  Colo.,  1901.  For  literature  on 
eugenics,  the  reader  is  referred  to  the  following  papers  and  the  references  therein 
contained :  "  Eugenics,  Its  Definition,  Scope,  and  Aims,"  by  Francis  Galton, 
American  Journal  of  Sociology,  Vol.  X,  pp.  1-6,  1904.  "  The  Scope  and  Im- 
portance to  the  State  of  the  Science  of  National  Eugenics,"  by  Karl  Pearson, 
Oxford  University  Press,  England.  "  Social  Darwinism,"  by  D.  Collin  Wells, 
Papers  and  Proceedings  of  the  American  Sociological  Society,  Vol.  I,  University 
of  Chicago  Press.  "The  Human  Harvest,"  by  David  Starr  Jordan,  Boston 
(American  Unitarian  Association),  1907.  "  Eugenics,"  by  Prof.  Albert  G.  Keller, 
Yale  Review,  August,  1908.  "A  First  Study  of  the  Statistics  of  Pulmonary 
Tuberculosis,"  by  Karl  Pearson,  Drapers  Company,  Research  Memoirs,  London 
(Delau  &  Co.),  1907. 


REPORT    ON    NATIONAL   VITALITY.  55 

Chapter  VII. — Conservation  through  public  hygiene. 
Section  1. — Municipal  hygiene. 

Whatever  improvements  in  heredity  may  sometime  be  achieved,  the 
benefits  of  their  influence  can  be  enjoyed  only  by  future,  perhaps  dis- 
tantly future,  generations.  We  of  the  present  generation  have  to  take 
our  heredity  as  we  find  it.  We  can  not  follow  the  advice  of  the  hu- 
morous philosopher  to  begin  life  by  selecting  our  grandparents ;  but, 
through  hygiene,  we  can  make  the  most  of  our  inherited  endowment. 
Even  such  a  limited  effort  offers  large — amazingly  large — rewards. 

Ideal  conditions  for  health  comprise  a  pure  and  disease- free  atmos- 
phere in  which  to  live  and  work ;  pure  food  and  a  pure  water  supply ; 
protection  from  infection  and  accident;  and  a  proper  adjustment  of 
work,  rest,  and  amusement.  Existing  conditions  are  not  only  far 
from  ideal,  but  also  far  from  what  might  easily  and  speedily  be 
attained. 

That  the  savin^.power  of  hygiene  is  great  is  now  universally  recog- 
nized; that  it  will  be  greater  is  the  hope  and  belief  of  those  most 
competent  to  judge.  "  If  hygiene  were  able  to  prolong  life  when  it 
was  little  developed,  as  was  the  case  until  recently,  we  may  well  be- 
lieve that,  with  our  greater  knowledge  of  to-day,  a  much  better  result 
will  be  obtained."  " 

There  is  every  reason  to  believe  that  human  beings  are  as  amenable 
to  cultivation  as  other  animals  and  plants.  Professor  Graves,  of  the 
Yale  Forest  School,  states  that  by  protecting  trees  from  infection 
their  lives  may  often  be  prolonged  a  century.  Domestic  animals  are 
equally  dependent  on  care.  Doctor  McGee  states  that  the  growth  of  a 
colt  may  be  stopped  by  giving  it  alcohol. 

The  methods  of  securing  improvement  in  health  conditions  may  be 
roughly  classified  under  three  groups:  Public  hygiene,  semipublic 
hygiene,  and  personal  hygiene.  The  first  group  refers  to  activities 
of  the  government;  the  second  refers  to  activities  of  the  medical 
profession  and  institutions  such  as  hospitals,  sanatoria,  schools,  and 
factories,  and  to  voluntary  associations;  the  third  group  deals  with 
the  private  life  of  the  family  and  the  individual.  Each  of  these 
three  groups  covers  phases  of  all  three  branches  of  hygiene,  viz, 
the  hygiene  of  environment,  nutrition,  and  activity.^ 

In  this  chapter  we  have  to  deal  with  public  or  governmental 
hygiene.  This  branch  has  been  chiefly  concerned  with  pure  air  and 
pure  food  and  with  organisms  producing  epidemic  diseases.  Boards 
of  health  are  a  recent  invention,  and  in  this  country  they  have  as  yet 
been  only  imperfectly  developed.  They  can  never  become  the  power 
they  should  be  until,  first,  public  opinion  better  realizes  their  use- 
fulness and  the  fact  that  their  cost  to  the  taxpayer  is  saved  many 
times  over  by  the  prevention  of  death  and  disease ;  second,  more  and 
better  health  legislation  is  enacted — national,  state,  and  municipal; 
and,  third,  special  training  is  secured  for  what  is  really  a  new  pro- 

«  Metclinikoff,  Prolongation  of  Life,  p.  144. 

*  Since  this  report  was  written  there  has  appeared  the  excellent  and  inspiring 
*'  Civics  and  Health,"  by  William  H.  Allen,  Bureau  of  Municipal  Research,  New 
York  (Ginn),  1909. 

84369— No.  30—09 5 


56  EEPOKT   ON   NATIONAL  VITALITY.  1 

fession,  that  of  public  health  officer — a  profession  already  recognized      ! 
in  England  by  a  special  diploma. 

The  health  officer  should  be  supported  entirely  by  the  salary  of  his  office  and 
should  be  absolutely  prohibited  from  practicing  medicine.  Not  only  are  his 
duties  incompatible  with  practice  quite  as  much  as  those  of  judges  with  the 
practice  of  law,  but  if  he  gives  them  proper  attention  there  is  no  time  for  other 
duties.  No  court,  police,  or  fire  department,  or  other  agency  of  government, 
can  be  more  important  to  a  people  than  this  under  the  complex  conditions 
incident  to  the  rapid  growth  of  both  rural  and  urban  populations.  It  is  so 
important  that  this  be  realized  that  it  is  worthy  of  serious  consideration  as  to 
whether  it  would  not  be  better  for  all  imperfectly  equipped  and  supported 
health  boards  in  this  country  to  resign — so  that  the  authorities  and  people 
would  be  brought  face  to  face  with  the  knowledge  that  they  have  no  real  pro- 
tection except  in  the  emergency  of  an  epidemic — than  for  existing  conditions  to 
continue. 

Laboratories,  research  workers,  statisticians,  and  other  facilities  for  the 
performance  of  a  national  board  of  health's  duties  should  be  furnished  in  pro- 
portion to  the  power  and  wealth  of  the  Government  and  the  vast  interests  it 
would  protect  and  promote.  The  results  of  its  scientific  and  collective  investi- 
gations should  be  constantly  utilized  in  promoting  health  in  the  army  and  navy, 
in  protecting  streams  and  soils  from  pollution,  in  the  construction  of  interstate 
waterways,  in  the  reclamation  of  swamp  lands,  and  in  other  public  works 
involving  health  problems  of  supreme  importance  to  the  future  of  this  country.'^ 

Public  hygiene  may  be  studied  under  three  heads,  corresponding  to 
our  governmental  divisions:  Municipal  hygiene,  state  hygiene,  and 
federal  hygiene. 

Municipal  hygiene  and  sanitation  are  placed  largely  in  the  hands  of 
city  boards  of  health,  or  equivalent  organizations,  which  have  power 
to  issue  sanitary  regulations,  abate  nuisances,  and  even  to  punish 
infractions  of  their  instructions  by  fine  and  imprisonment.  Sanitary 
legislation  is  a  product  of  advanced  civilization.  To-day  not  a  city 
is  without  a  board  of  health.  The  powers  of  these  boards  have 
grown,  till  to-day  they  are  by  no  means  inconsiderable;  yet  they 
m.ust  be  given  even  greater  authority,  if  our  municipal  sanitary  con- 
ditions are  to  be  what  they  should.  Public  apathy  and  political 
interference  are  such  that  health  authorities  can  not  enforce  their 
orders.  In  addition  to  the  acquirement  of  greater  power,  city  health 
boards  often  need  purification  of  motive  and  the  banishment  of 
political  bickerings  and  personal  jealousies. 

The  simplest  ordinances  along  the  line  of  public  hygiene  are  those 
against  spitting,  which  now  remain  so  largel;^  unenforced. 

The  smoke  nuisance  is  another  seemingly  simple  form  of  air  vitia- 
tion that  is  receiving  attention  to-day.  Sulphuric  acid  is  apparently 
the  most  injurious  factor.  The  corrosion  of  stone  structures  suggests 
the  irritation  resulting  in  catarrh  and  other  respira,tory  mucous- 
membrane  troubles.^ 

The  effect  of  the  introduction  of  closed  sewers  on  the  reduction  of 
tuberculosis  should  not  be  overlooked.  By  closing  sewers,  impure 
gases  have  been  confined,  thereby  removing  an  important  source  of 
air  pollution.  Some  cities  realize  that  pure  air  spells  life  and  health 
to  its  inhabitants,  and  that  pure  air  is  a  possibility  only  when  atmos- 
pheric particles  of  soot  and  dirt  are  removed. 

Regulations  governing  garbage  removal,  notification  and  isolation 
of  disease,  and  the  like  are  as  a  rule  enforced,  and  new  regulations 
are  being  issued  constantly.    Substantial  progress  is  shown  each  year 

"Letter  from  Dr.  J.  N.  McCormack. 

*  See  Journal  American  Medical  Association,  September  7,  1907,  p.  813. 


EEPORT   ON    NATIONAL  VITALITY.  57 

in  the  purification  of  city  water  supplies,  in  the  improvement  of  sew- 
age disjoosal,  and  in  the  bettering  of  drainage  conditions.  Streets 
are  more  thoroughly  cleaned  and  the  elimination  of  public  and  private 
nuisances  continues  without  ceasing. 

Our  city  streets  have  received  greater  care  since  Colonel  Waring 
organized  his  "  white  wings  "  brigade  in  New  York  City  a  dozen 
years  ago,  thus  proving  the  great  effectiveness  of  clean  streets  in  the 
elimination  of  disease.  The  probable  elimination  of  the  horse  from 
our  city  life,  through  automobiles,  the  betterment  of  our  trolley  sys- 
tems, and  the  introduction  of  subways  (especially  freight  subways) 
will  go  far  to  improve  our  city  atmosphere.  The  problem  of  city  air 
will  be  half  solved  when  our  streets  reach  their  proper  state  of  clean- 
liness. The  gradual  elimination  of  the  horse  will  tend  not  only  to 
produce  cleaner  air,  but  also  to  reduce  the  dangers  from  flies.  It  is 
in  horse  manure  that  the  common  housefly  ("  typhoid  fly  ")  chiefly 
breeds.  Doctor  Howard  attributes  the  termination  of  typhoid  in 
certain  parts  of  Washington  to  the  displacement  of  the  horse  by  the 
automobile. 

Only  within  a  dozen  j^ears  has  the  dread  importance  of  insect  car- 
riers of  disease  been  realized.  That  mosquitoes  carry  malarial  germs ; 
that  flies  are  the  propagators  of  typhoid,  cholera,  and  other  infectious 
diseases ;  that  rats  breed  the  fleas  which  transmit  to  man  the  dreaded 
Asiatic  plague  '^ — all  this  knowledge  is  of  recent  origin.^ 

Well  people  are  sometimes  carriers  and  distribute  typhoid,  diph- 
theria, etc.,  a  fact  which  complicates  public-health  regulations. 

The  simple  reporting  of  all  contagious  disease  to  the  health  au- 
thorities immediately  on  its  appearance  is  often  the  means  of  prevent- 
ing an  epidemic. 

Smallpox  epidemics  are  prevented  both  by  quarantine  and  vacci- 
nation. Because  of  the  outcry  against  compulsory  vaccination,  in  some 
places  the  responsibility  for  vaccination  is  being  thrown  upon  the 
individual.  This  is  true  in  Leicester,  England,  and  in  Minnesota. 
Doctor  Bracken,  secretary  of  the  Minnesota  State  Board  of  Health, 
writes  that  since  the  quarantine  has  been  abandoned  and  the  indi- 
vidual has  had  the  option  of  being  vaccinated  or  not,  a  larger  number 
has  been  vaccinated  and  smallpox  has  diminished. 

We  are  awaking  to  the  importance  of  securing  for  ourselves, 
through  our  city  health  agencies,  a  pure  milk  supply.  Great  danger 
is  also  present  in  cream,  butter,  cheese,  and  ice  cream.  More  than  one 
city  has  inaugurated  a  policy  of  careful  supervision  of  the  milk  sup- 
ply. Montclair,  N.  J.,  has  a  well-considered  plan  in  operation 
whereby  the  bacterial  count  of  each  dairy  is  public  to  inquirers  at 
the  board  of  healtti.  This  species  of  publicity  will  some  day  prove  a 
strong  incentive  to  a  better  milk  supply.  Some  cities  have  even  estab- 
lished municipal  stations,  where  during  the  summer  season  sanitary 
milk  may  be  purchased  at  cost.  Doctor  Goler,  of  Rochester,  has  em- 
phasized the  fact  that  "  We  employ  physicians  to  cure  children  af- 

<^  See  Rupert  Bine,  "  The  prophylaxis  and  eradication  of  plague,"  California 
State  Journal  of  Medicine,  Vol.  V,  1907,  p.  304. 

*A  full  treatment  of  the  subject  of  insect-borne  disease  has  been  prepared 
by  Dr.  L.  O.  Howard,  Chief  of  the  Bureau  of  Entomology  of  the  Department  of 
Agriculture,  for  the  National  Conservation  Commission.  See  also  Charles  Har- 
rington, M.  D.,  "Practical  Hygiene,"  Third  Edition,  Philadelphia  (Lea),  1905, 
pp.  637-660. 


58  KEPOET   ON   NATIONAL  VITALITY. 

fected  by  the  diarrheal  diseases  from  dirty  milk,  while  we  permit  the 
sale  of  dirty  milk  from  filthy  cattle."  '^ 

In  jHochester,  through  the  efforts  of  Doctors  Goler  and  Roby,  a  few 
municipal  milk  stations  were  established  in  1897,  where  during  July 
and  August  milk  in  nursing  bottles  could  be  bought  at  a  low  price. 
The  reduction  in  the  Rochester  infant  death  rate  between  1897  and 
1906  is  doubtless  due  to  many  other  conditions  than  the  quality  of 
milk ;  but  the  special  attention  drawn  to  the  milk  supply  and  the  con- 
sequent education  of  the  public,  which  probably  boiled  its  milk  when 
it  could  not  get  it  clean,  would  explain  a  considerable  part  of  the 
reduction.^ 

The  interrelation  of  the  purity  of  milk  supply  and  infant  mortality 
is  shown  by  the  following  excerpt  from  Doctor  Woodward's  annual 
report  as  health  officer  of  the  District  of  Columbia  for  the  year  1907 : 

High  as  is  the  infantile  mortality  even  now  from  diarrhea  and  inflammation 
of  the  bowels,  it  is  far  below  the  figures  that  formerly  prevailed. 

The  only  explanation  for  the  fall  in  the  death  rate  from  infantile  diarrhea 
that  I  have  been  able  to  discover  is  the  enactment  on  March  2,  1895,  of  the  law 
regulating  the  saK  ^^  jailk  in  this  District  and  the  establishment  of  dairy  and 
dairy-farm  inspection  under  the  provision  of  that  law. 

The  weekly  report  of  the  Cincinnati  board  of  health  for  August 
21,  1908,  states: 

As  far  as  we  know,  there  has  been  but  one  death  among  the  babies  whose  food 
supply  has  been  obtained  from,  the  milk  stations.  When  it  is  taken  into  con- 
sideration the  large  number  of  children  we  have  supplied,  this  statement  is 
certainly  a  fitting  commentary  upon  the  value  of  a  bacteria-free  and  chemically 
pure  milk. 

At  the  recent  International  Congress  on  Tuberculosis,  one  delegate 
reported  an  experiment  in  England  which  has  not  yet  appeared  in 
print.  In  Liverpool  the  local  government  board  tried  the  experiment 
of  using  pasteurized  milk.  The  amount  of  illness  and  death  in  that 
eity  from  children's  tuberculosis  is  very  great,  yet  among  1,800  chil- 
dren who  were  given  pasteurized  milk  and  who  were  carefully 
watched  every  week  not  a  single  case  of  tuberculosis  developed, 
which  seems  to  prove  conclusively  that  children's  tuberculosis  is  en- 
tirely preventable  by  the  use  of  pure  or  pasteurized  milk.  This  is 
interesting,  though  at  variance  with  former  opinion  regarding  bovine 
tuberculosis  in  children. 

In  this  section  should  also  be  mentioned  such  municipal  health 
agencies  as  public  baths,  bacteriological  laboratories,  and  the  dis- 
tribution and  administration  of  specific  antitoxin,  vaccine,  and  free 
medical  service.  Municipal  inspection  of  local  abattoirs  is  also  im- 
portant, inasmuch  as  federal  inspection  covers  only  establishments 
engaged  in  interstate  business. 

Most  important  of  all  is  the  matter  of  prevejting  pollution  of  the 
water  supply  of  cities,  a  topic  that  will  receive  fuller  treatment  later 
in  the  chapter. 

"  See  George  W.  Goler,  M.  D.,  "  Municipal  regulation  of  the  milk  supply," 
paper  at  the  meeting  of  the  American  Medical  Association,  1907,  p.  2.  For  con- 
clusions based  on  a  study  of  330  milk-borne  epidemics,  see  George  M.  Ko- 
ber,  M.  D.,  "Milk  in  relation  to  public  health,"  S.  Doc.  No.  441,  Government 
Printing   Office,   1902. 

*  See  George  W.  Goler,  M.  D.,  "  Origin,  development,  and  results  of  municipal 
milk  work  in  Rochester,  N.  Y.,"  Maryland  Medical  Journal,  June,  1906. 


KEPORT   ON   NATIONAL  VITALITY.  59 

The  needs  of  municipal  as  of  state  hygiene  are  not  so  much  new 
laws  as  better  men  to  enforce  existing  laws  and  an  aroused  public 
opinion  that  will  result  in  the  appropriation  of  funds  sufficient  to 
enable  health  authorities  to  perform  their  duties  in  an  efficient  man- 
ner. Larger  appropriations  will  doubtless  bring  better  men  into  the 
public-health  service. 

Section  2. — State  hygiene. 

State  hjrgiene  is  necessary  to  supplement  municipal  hygiene  for 
many  reasons.  One  is  that  the  country  often  has  no  other  sort  of 
sanitation  possible.  Another  is  that  the  city  is  dependent  on  the 
country  for  its  water,  milk,  and  other  supplies.  Dr.  W.  G.  Daggett, 
of  New  Haven,  has  emphasized  the  fact  that  in  origin  typhoid  is 
largely  a  rural  disease  and  must  be  combated  by  controlling  rural 
privies  and  other  sources  of  infection.^  A  competent  authority  as- 
serts that  "  old  country  wells,  so  much  valued  by  their  owners,  are 
a  positive  menace  to  public  health.  Fully  50  per  cent  of  these  are 
unfit  for  use."  Much  of  the  typhoid  fever  brought  by  milk  is  readily 
traceable  to  such  wells. 

In  the  control  of  the  liquor  traffic  the  State  and  local  units  should 
cooperate,^ 

A  state,  rather  than  a  municipal,  function  is  the  regulation  of 
woman  labor  and  child  labor.  The  growth  of  public  opinion  on  this 
point  has  been  rapid.  In  order  to  make  the  working  hours  meet 
the  physiological  requirements  of  women,  two  special  conditions 
should  be  attended  to.  One  is  her  monthly  period ;  the  other  is  child- 
bearing.  The  neglect  of  both  is  responsible  not  only  for  physical 
impairment  of  factory  women,  but  also  for  their  inability  to  perform 
their  functions  as  mothers  of  the  race.  Doctor  Stiles,  of  the  Public 
Health  and  Marine-Hospital  Service,  has  suggested  a  very  sensible 
remedy  to  meet  the  first  of  these  conditions,  and  one  which  has  met 
with  the  approval  of  many  factory  employers..  It  is  that  each  woman 
shall  have  the  right,  once  every  month,  to  walk  out  of  the  factory 
without  any  questions  being  asked,  and  without  loss  of  the  day's 
wages.  The  matter  is  further  simplified  in  factories  provided  with  a 
matron  and  a  rest  room.  In  respect  to  the  second  condition — that  of 
childbearing — the  evidence  is  clear  and  convincing.  Women,  on 
account  of  their  imperfectly  developed  muscular  system  and  more 
delicate  physique,  are  unfitted  for  hard  work;  nor  should  they  be 
obliged  to  work  steadily  in  a  sedentary  position,  especially  at  the  sew- 
ing machine,  or  other  occupations  involving  the  use  of  the  lower 
extremities.  Special  protection  should  be  extended  to  them  during 
the  childbearing  period.  It  is  a  matter  of  constant  observation  that 
women  who  have  to  deny  themselves  proper  rest  and  care  during  the 
next  six  weeks  after  confinement  are  very  liable  to  suffer  from  hemor- 
rhages and  chronic  uterine  diseases,  while  miscarriages  and  prema- 
ture births  are  not  infrequent  results  of  overwork." 

°' "  The  prevention  of  typhoid  fever,"  Proceedings  Connecticut  Medical  So- 
ciety, New  Haven. 

*  See  "  Regulation  of  the  liquor  traffic,"  Annals  American  Academy  of  Political 
and  Social  Science,  November,  1908. 

'^  George  M.  Kober,  M.  D.,  "  Industrial  and  personal  hygiene,"  "  Report  of 
Committee  on  Social  Betterment  of  the  President's  Homesi  Commission,"  Wash- 
ington, 1908,  pp.  67-68. 


60  REPORT   ON   NATIONAL  VITALITY. 

The  employment  of  mothers  shortly  before  and  after  the  time  of 
childbirth  is  prohibited  in  a  number  of  European  countries.  Ameri- 
can statutes,  however,  are  almost  silent  on  the  question.*^  Professor 
Jevons  went  so  far  as  to  advocate  the  enactment  of  legislation  forbid- 
ding the  employment  of  mothers  till  their  youngest  children  were  at 
least  3  years  old. 

The  beneficial  effect  on  the  mother,  and  especially  on  the  child,  of 
forbidding  the  factory  to  her  just  before  and  after  childbirth  has 
been  proved  many  times.  The  case  of  M.  Dollfus,  a  large  employer 
of  women  at  Mulhausen,  in  Alsace,  has  been  repeatedly  cited.  He 
required  mothers  to  remain  away  from  their  work  for  a  period  of 
six  weeks  after  childbirth,  during  which  time  he  paid  them  full 
wages.  The  decrease  in  infantile  mortality  in  the  first  year  of  the 
experiment  was  from  more  than  40  to  less  than  18  per  cent.^ 

The  waste  of  vitality  from  unphysiological  hours  of  work  is  most 
striking  in  the  case  of  children.  It  is  hardly  to  be  questioned  that 
children  need  longer  hours  of  rest  and  sleep  than  adults,  and  that 
their  immature  bodies  are  much  closer  to  the  fatigue  limit.  A  little 
girl  in  a  southern  mill  replied  to  Mrs.  Van  Vorst's  query  whether  she 
were  often  tired,  "  ^Vhy,  I'm  always  tired."  Except  in  unusual  cases 
and  for  limited  periods,  child  factory  labor  can  not  be  defended  on 
any  hygienic  grounds.  The  period  of  preparation  for  a  wholesome, 
healthy  life  should  be  left  free  from  the  cares  and  evil  physical  in- 
fluences of  factory  life.  No  child  should  run  the  risk  of  serious  acci- 
dent, deformity,  dwarfing,  or  mental  stunting  through  factory  labor. 
It  is  true  that  in  the  South  child  labor  is  often  the  lesser  of  two 
evils,  the  other  being  the  life  on  a  farm  where,  through  soil  pollu- 
tion, the  child  contracts  hook-worm  disease.  Here  the  abolition  of 
child  labor  should  be  preceded  by  the  abolition  of  hook-worm  disease." 

Closely  connected  with  the  restriction  of  child  and  woman  labor 
is  factory  legislation  in  general,  dealing  with  hours  of  labor,  factory 
hygiene  and  sanitation,  and  dangers  from  industrial  accident. 

The  hours  of  labor  have  for  a  century  been  on  a  gradual  decrease. 
A  hundred  years  ago  fourteen  and  fifteen  hours  were  by  no  means  un- 
common. The  first  public  action  regarding  hours  of  labor  was  taken 
by  President  Van  Buren  in  1840,  when  he  set  ten  hours  as  the  limit 
of  the  working  day  in  all  government  establishments.  Thirty  years 
later  this  was  lowered  by  Congress  to  eight  hours.  Since  1850  the 
fight  has  been  waged  for  a  shorter  day,  both  by  labor  unions  and 
individuals;  and  the  statutes  of  nearly  all  States  contain  legislation 
limiting  the  working  hours  of  women  and  children  in  all  industries, 
as  well  as  of  all  workers  in  certain  industries,  especially  mining,  rail- 
roading, and  the  more  dangerous  manufacturing  industries.  The 
Aldrich  report  of  1890  ^  estimated  that  the  American  working  day 
averaged  eleven  and  four-tenths  hours  in  1840  and  ten  hours  in  1890. 
Tables  based  upon  annual  reports  of  the  Bureau  of  Labor  show  a 
reduction  of  about  4  per  cent  from  1890  to  1903,^  while  it  is  the 

ttjohn  Spargo,  "The  Bitter  Cry  of  the  Children,"  New  York  ( Macmillan ) , 
1906,  pp.  44-45. 

^  Spargo,  loc.  cit,  pp.  50-51. 

<=  See  '•  Report  of  the  Surgeon-General  of  the  Public  Health  and  Marine- 
Hospital  Service  for  1907,"  relating  to  the  investigations  of  Doctor  Stiles. 

^  "  Report  on  Wholesale  Prices  and  Wages,"  1890,  Vol.  I,  p.  178. 

«T.  S.  Adams  and  Helen  L.  Sumner,  "Labor  Problems,"  New  York  (Macmil- 
lan), 1905,  pp.  516-518. 


EEPORT   ON    NATIONAL  VITALITY.  61 

opinion  of  United  States  Commissioner  of  Labor  Neill  that  the 
figures  for  1908  would  unquestionably  be  lower  than  for  1903,  as  the 
struggle  for  the  shorter  working  day  has  been  making  steady  prog- 
ress each  year." 

The  frightful  losses  of  life  and  efficiency  from  preventable  acci- 
dents can  be  prevented  only  by  state  legislation.^ 

Our  employer's  liability  acts  are  very  unsatisfactory,  because  they 
fix  no  scale  of  compensation  for  injuries,  but  necessitate  expensive 
lawsuits  to  determine  in  each  case  the  sum  due.  A  president  of  an 
insurance  company  doing  a  large  business  in  employer's  liability 
insurance  states  that  of  the  sums  they  pay  employers  only  one-quarter 
reaches  the  injured  employee,  who  is  forced  to  spend  the  other  three- 
fourths  in  litigation.  In  England  the  workman's  compensation  acts 
have  substituted  a  system  of  specific  sums  for  which  the  employer  is 
liable.  Not  only  does  this  result  in  larger  indemnities  reaching  the 
injured,  because  suits  are  ordinarily  unnecessary,  but  it  has  the  fur- 
ther beneficial  effect  of  reducing  the  number  of  accidents  by  inducing 
employers  to  instal  safety  devices. 

The  regulation  not  only  of  the  place  of  work,  but  also  of  the  dwelling 
place,  has  come  to  demand  action  on  the  part  of  the  State  as  well 
'  as  of  the  community.  The  growth  in  tenement-house  legislation  dur- 
ing the  past  ten  years  has  been  most  encouraging.  Standards  of 
sanitation  for  our  large  buildings  have  been  raised;  provision  is  in- 
creasingly made  for  good  light,  air,  water,  and  for  protection  from 
fire ;  and  the  "  rookeries  "  of  old  are  giving  way  to  improved  tene- 
ments. Yet  New  York  City  still  contains  300,000  rooms  without  a 
window.*' 

Section  3. — Federal  hygiene. 

The  regulation  of  disease  has  increasingly  become  a  national  func- 
tion. The  exclusion  of  immigrants  with  infectious  diseases  is  only 
one  instance  of  this;  another  is  the  work  of  our  Public  Health  and 
Marine-Hospital  Service,  which  not  only  regulates  the  spread  of  dis- 
ease from  State  to  State,  and  regulates  by  q.uarantine  the  entry  of 
disease  from  without  the  country,  but  also  assists  local  health  boards 
in  their  fights  against  epidemics  and  disease  scourges.  Specially  is 
this  true  in  coastal  cities.  The  Marine-Hospital  Service  assisted  New 
Orleans  to  eliminate  yellow  fever  and  San  Francisco  to  rid  itself 
of  bubonic  plague.  In  addition,  this  service  treats  50,000  seamen 
of  the  merchant  marine  each  year,  conducts  a  large  number  of  hos- 
pitals and  relief  stations,  examines  pilots,  life-saving  crews  and 
revenue-service  men,  and  conducts  a  well-equipped  hygienic  labora- 
iovy. 

Federal,  state,  and  municipal  sanitation  are  all  concerned  with  the 
hygiene  of  transportation.  To-day  almost  the  whole  American  pub- 
lic travels,  and  it  is  therefore  most  important  that  the  conveyances 

<^  See  Bulletin  of  the  Bureau  of  Labor,  No.  77,  July,  1908,  pp.  6-7 ;  also,  "  First 
Annual  Report  on  Changes  in  Rates  of  "Wages  and  Hours  of  Labor  in  Massachu- 
setts," Boston,  1908,  pp.  592-3. 

^  The  Federal  Government  can  of  course  reach  interstate  railways.  A  law 
passed  during  the  last  session  provided  for  a  safe  locomotive  ash  pan.  Previous 
laws  provide  for  automatic  couplers,  air  brakes,  etc. 

"  A.  Jacobi,  M.  D.,  "  The  physical  cost  of  women's  work,"  Charities,  February 
2,  1907. 


62  EEPOET    ON    ISTATIONAL   VITALITY. 

which  they  occupy,  whether  carriage,  cab,  street  car,  or  railway  train^ 
shall  be  sanitary  in  respect  to  ventilation,  cleanliness,  toilet  facilities, 
spittoons,  dust,  smoke,  sleeping-car  accommodations,  and  the  like. 
In  smoking  cars,  in  addition  to  the  smoke  itself,  the  floors  are  usually 
befouled  with  tobacco  juice  and  other  expectoration.  The  efficient 
remedy  here  as  elsewhere  is  to  be  found,  not  simply  in  providing 
facilities  for  cleanliness,  but  in  fostering  the  present  public  sentiment 
against  spitting  and  other  untidy  habits.  A  physician  of  experience 
maintains  the  opinion  that  "  foul  air  in  railway  trains  and  street 
cars  is  the  cause  of  serious  poisonings  called  '  colds '  and  '  grip,'  par- 
ticularly in  those  many  trains  where  air  from  the  smoker  sweeps 
through  passenger  cars." 

The  development  of  our  national  quarantine  methods  is  indicated 
in  the  following  paragraph  from  Surgeon-General  Wyman,  of  the 
Public  Health  and  Marine-Hospital  Service : 

Until  1893  there  was,  properly  speaking,  no  national  system  of  quarantine. 
The  colonies  had  their  own  quarantine  regulations  before  the  formation  of  the 
Union,  and  from  that  event  to  1893  quarantine  was  left  to  the  care  of  state 
governments  and  by  the  latter  to  county  governments  or  to  municipalities,  as 
the  case  might  be.  There  was,  indeed,  national  legislation,  but  all  the  acts 
of  Congress  up  to  1893  relating  to  quarantine  specially  provided  that  the  said 
national  measures  were  in  aid  of  the  state  and  local  authorities.  Whatever 
opinions  may  have  been  held  by  members  of  the  national  legislature,  quarantine 
was  permitted  to  be  exercised  by  the  States  as  a  police  function,  and  even  in 
the  present  law,  which  gives  national  supremacy,  it  is  provided  that  assistance 
shall  be  given  the  States  or  municipalities  by  the  government  authorities,  the 
supremacy  of  the  latter  being  asserted  only  when  the  state  or  local  authorities 
fail  or  refuse  to  enforce  the  uniform  national  regulations.'^ 

To-day  efficient  inspection  at  our  various  ports  of  entry  and  at 
disembarking  stations  abroad  keejDS  out  many  cases  of  disease  each 
year,  while  the  quarantine  cordon  thrown  around  ports  or  municipal 
quarters  affected  by  infectious  disease  is  an  important  factor  in 
stamping  out  such  disease. 

Federal  meat  inspection  chiefly  benefits  the  foreigner,  but  the  ad- 
ministration of  the  pure-food  laws  is  of  value  to  our  own  people. 

There  are  two  functions  of  Federal  Government  which  now  are 
very  imperfectly  served  and  which  might  be  made  of  paramount 
importance.  They  are  the  functions  of  research  and  of  the  dis- 
semination of  information.  A  poultry  raiser,  or  a  cattleman,  or  a 
farmer  can  secure  scientific  information  to  guide  him  in  his  selections 
of  fowl,  or  stock,  or  seed  by  applying  to  the  Government  at  Washing- 
ton, but  information  on  how  to  raise  children  has  up  to  this  time  been 
neglected  by  our  Government.  Nothing  is  to-day  more  significant  of 
future  progress  than  the  fact  that  the  President,  the  President-elect, 
and  many  Congressmen  are  so  strongly  in  favor  of  a  greater  federal 
organization  of  health.  Through  the  dissemination  of  information 
throughout  the  country,  through  enactment  and  administration  of 
effective  regulations  concerning  pure  food,  inspection  of  meat,  and 
exclusion  of  foreign  diseases,  through  research,  statistics,  and  through 
better  standards  for  state  and  municipal  health  service,  a  great  econ- 
omy of  national  vitality  can  be  effected,  Washington,  our  national 
capital,  might  be  made  by  the  Federal  Government  a  model  city  of 

"  Walter  Wyman,  M.  D.,  "  The  quarantine  system  of  the  United  States," 
The  Sanitarian,  November,  1897,  p.  3.  See  also  James  W.  Garner,  "  Federal 
activity  in  the  interest  of  the  public  health,"  Yale  Review,  1905-6,  p.  181. 


KEPORT   ON    NATIONAL  VITALITY,  63 

health  fulness,  as  a  preliminary  to  its  becoming  a  model  in  every 
other  way. 

Army  hygiene  in  time  of  war  is  most  important.  The  lack  of  such 
hygiene  has  shown  grave  consequences.  In  the  Boer  war  the  British 
army  in  South  Africa  lost  more  men  from  typhoid  fever  than  from 
wounds  received  in  battle." 

The  eiRciency  of  Japanese  hygiene  manifests  itself  in  the  fact  that 
General  Oku's  army  of  75,000  during  the  recent  Russo-Japanese  war 
had  but  187  typhoid  fever  cases  in  a  seven  months'  active  campaign. 

The  Japanese  reduced  their  dysentery  cases  from  12,052  in  the 
Chinese  war  to  6,624  in  the  Russian  war;  their  cholera  cases  from 
7,667  to  none ;  and  their  malaria  cases  from  41,734  to  1,257.  This  was 
in  spite  of  the  fact  that  their  army  in  the  Russian  war  was  three 
times  the  size  of  that  employed  in  the  Chinese  war.^ 

The  crying  need  of  better  statistics  is  trenchantly  expressed  by  Dr. 
Cressy  L.  Wilbur,  Chief  of  the  Division  of  Vital  Statistics  of  the  Cen- 
sus Bureau,  whose  words  should  be  read  and  pondered  by  everA'^one 
who  desires  to  see  any  intelligent  conservation  of  our  vital  resources : 

Sound  vital  statistics  are  the  indispensable  basis  of  modern  sanitation.  A 
nation  that  does  not  consider  it  necessary,  or  that  is  not  able,  to  provide  ade- 
quate means  for  registering  the  births  of  its  own  children,  or  for  officially 
recording  the  deaths  of  its  citizens,  can  hardly  be  supposed  to  attach  sufficient 
value  to  human  life  to  enable  sanitary  measures  for  its  conservation  to  be  ade- 
quately carried  out. 

For  the  continental  Lfnited  States  in  1907  somewhat  less  than  one-half  of  the 
total  population  (4S.8  per  cent)  was  represented  in  the  registration  area  from 
which  returns  of  deaths  were  received  by  the  Bureau  of  the  Census.  For  the 
remaining  51.2  per  cent  of  the  total  population  of  the  United  States,  estimated 
at  43,774,724  persons,  either  very  imperfect  laws  were  in  effect,  giving  only 
partial  registration,  quite  worthless  for  statistical  purposes,  or  else  the  condi- 
tions in  many  States  might  be  represented  by  the  statement  made  by  one  ot 
their  health  officers,  that  it  buries  its  dead  people  with  no  more  ceremony  than 
it  buries  its  dead  dogs. 

As  for  the  registration  of  births,  a  measure  which  Is  so  supremely  important 
for  the  knowledge  of  infant  mortality,  for  the  protection  of  infant  life,  and  for 
securing  the  legal  rights  of  children,  not  a  single  State  in  the  Union  nor  a  single 
city  of  any  considerable  size  makes  positive  claim  that  it  registers  as  many  as 
nine  births  out  of  every  ten  that  occur.  Even  the  city  of  Washington,  whose 
law  for  this  purpose  is  a  direct  enactment  of  Congress,  does  not  arise  above 
this  low  limit  of  efficiency.  The  total  number  of  births  must  be  known  before 
one  can  make  a  computation  of  infant  mortality  which  will  be  comparable  with 
the  rates  given  in  the  vital  statistics  of  all  civilized  nations  except  the  United 
States.  This  ratio  depends  upon  the  comparison  of  deaths  of  infants  under  1 
year  of  age  with  total  births,  and,  as  we  have  no  exact  registration  of  births, 
we  can  not  present  these  important  statistics. 

In  the  consideration  of  the  effect  of  such  an  important  disease  as  tuberculosis 
upon  the  people  of  the  United  States  there  is  no  means  of  knowing,  within  a 
very  wide  margin  of  error,  exactly  how  many  persons  die  from  this  cause  in 
this  country  during  any  year.  We  have  registration  of  deaths  for  about  one- 
half  of  the  population  only,  and  the  very  dissimilar  conditions  of  life  and  the 
large  proportion  of  colored  population  in  the  unregistered  half  seriously  inter- 
fere with  any  attempts  to  guess  at  the  exact  number.  Estimates  have  varied 
from  138,000  to  200,000.  The  truth  probably  lies  somewhere  between  them,  but 
we  certainly  ought  to  have  an  exact  record  of  the  facts  and  not  be  obliged  to 
depend  upon  mere  guesswork  in  entering  upon  an  important  sanitary  under- 
taking, such  as  the  prevention  of  tuberculosis. 

"■  Ditman,  loc.  cit.,  p.  17. 

*L.  L.  Seaman,  "The  Real  Triumph  of  Japan,"  New  York  (Appleton),  1906, 
pp.  106-7. 

On  the  question  of  army  diet,  see  Blackham :  British  Medical  Journal,  1908, 
August  8,  p.  811. 


64  EEPOET    ON    NATIONAL   VITALITY. 

We  are  laboring,  in  conjunction  with  the  American  Medical  Association,  the 
American  Public  Health  Association,  and  with  the  sanitary  officials  of  as  many 
States  as  we  can  interest,  to  extend  the  registration  area  as  rapidly  as  possible. 
Ohio  has  just  adopted  an  excellent  law,  which  takes  effect  next  year.  Not  a 
single  State  in  the  South  has  yet  succeeded  in  reaching  a  satisfactory  stand- 
ard— not  one  of  them  in  fact  has  even  passed  an  adequate  law.  We  are  de- 
pending upon  the  voluntary  cooperation  of  the  States.  The  Government  has  no 
power,  it  would  seem,  to  collect  the  statistics  or  to  secure  the  proper  registration 
of  births  and  deaths  by  its  direct  action.  If  all  of  the  important  interests  in- 
volved could  be  awakened  to  the  importance  of  this  matter,  if  Congress  would 
take  a  direct  interest  in  the  accomplishment  of  this  work,  we  could  secure  fairly 
complete  registration  of  deaths  for  the  United  States  within  the  next  ten  years." 

Chapter  YIII. — Conservation  through  semipuhlic  hygiene. 
Section  1. — Medical  research  and  instruction. 

By  semipublic  hygiene  is  meant  hygiene  through  nongovernmental 
institutions,  including  institutions  for  medical  research,,  the  medical 
profession,  hospitals,  sanatoria,  associations,  schools,  and  factories. 

Medical  discoveries  have  usually  been  made  in  the  laboratories  of 
medical  schools,  universities,  and  research  institutions.  The  practical 
value  of  these  institutions  is  only  beginning  to  be  appreciated.  The 
benefits  already  received  from  them  are  great,  and  the  benefits  to  come 
will  be  incomparably  greater.  One  of  the  earliest  medical  labora- 
tories, the  Pasteur  Institute  of  Paris,  has  done  splendid  work  during 
the  past  two  decades  in  the  study  of  harmful  and  beneficent  bacteria. 
Of  more  recent  origin  are  the  British  Sanitary  Institute  in  London, 
the  Rockefeller  Institute  for  Medical  Research,  the  Memorial  Insti- 
tute for  Infectious  Diseases  at  Chicago,  and  the  Nutrition  Research 
Laboratory  in  Boston,  under  the  Carnegie  Institute  of  Washington. 
The  recent  achievement  of  Dr.  Simon  Flexner  in  finding  a  serum  for 
the  treatment  of  meningitis  is  but  one  example  of  what  well-directed 
research  under  the  auspices  of  such  institutions  can  accomplish.  The 
crowning  achievement  of  science  in  the  present  century  should  be^ 
and  probably  will  be,  the  discovery  of  practical  methods  of  making 
human  life  healthier,  longer,  and  happier  than  heretofore. 

The  medical  schools  in  this  country  number  156.  They  are  rapidly 
advancing,  although  the  great  majority  are  still  ill  equipped  for  pro- 
viding intending  practitioners  with  the  most  recent  and  useful  knowl- 
edge. The  future  practice  of  medicine  depends  more  on  the  character 
and  aims  of  the  medical  schools  of  to-day  than  on  any  other  factor. 
At  the  dedication  of  the  Harvard  medical  buildings  in  1906,  President 
Eliot  laid  down  as  the  primary  duties  of  that  school  the  study  of  the 
prevention  of  disease  and  the  education  of  the  public.  The  need  of 
such  a  school  especially  devoted  to  prevention  has  been  fully  dis- 
cussed by  Doctor  Ditman.^  Several  universities  have  courses,  or  are 
taking  steps  to  give  courses  in  the  fields  not  only  of  public  hygiene 
and  preventive  medicine,  but  also  of  personal  hygiene  and  home 
economics. 

"■  Letter  from  Dr.  Cressy  L.  Wilbur.  See  also  Irving  Fisher,  "  Mortality  sta- 
tistics of  the  United  States  census,"  publication  of  the  American  Economic 
Association,  1899 ;  and  R.  Dudfield,  "  A  critical  examination  of  the  methods  of 
recording  and  publishing  statistical  data  bearing  on  public  health,"  Journal  of 
the  (Royal)  Statistical  Society,  March,  1905. 

*  See  N.  E.  Ditman,  M.  D.,  "  Education  and  its  economic  value  in  the  field  of 
preventive  medicine,"  Columbia  University  Press,  Vol.  X,  supp.  to  No.  3,  June, 
1908. 


EEPORT   ON    NATIONAL  VITALITY.  65 

One  diificulty  in  establishing  such  a  school  is  the  lack  of  students 
who  can  afford  the  means  or  the  time  to  attend.  This  was  the  ex- 
perience of  the  George  Washington  University,  in  Washington,  when 
a  course  of  this  kind  was  offered.  For  this  reason  it  is  gratifying  to 
see  that  an  effort  is  being  made  to  throw  open  the  research  laboratory 
of  the  Public  Health  and  Marine-Hosjoital  Service  for  the  use  of 
health  officers  detailed  from  their  several  States  and  municipalities. 
In  England  the  degree  of  D.  P.  H.  (diploma  in  public  health)  is  given 
those  who  meet  the  high  standard  set  there  for  health  officers. 

During  the  last  few  years  the  American  Medical  Association  has 
been  seeking  to  study,  classify,  and  improve  the  medical  schools  in 
the  United  States.  A  large  committee,  of  which  the  writer  is  one 
member,  has  been  appointed  by  the  association  to  consider  methods 
of  securing  such  improvements  as  are  deemed  necessary.  It  includes 
in  its  scope  the  important  but  heretofore  little  appreciated  field  of 
medical  economics. 

Section  2. — The  medical  profession. 

We  come  next  to  the  part  played  by  physicians,  so  far  as  relates  to 
their  "  private  practice."  Their  work  as  public  health  officers  has 
already  been  mentioned,  and  does  not  concern  us  here.  Their  work 
in  the  home  is  of  primary  importance.  It  is  on  the  physician  that  the 
average  man  relies  for  protection  when  he  finds  himself  in  the  dread 
grip  of  disease. 

Private  practice  comprises  two  main  divisions,  surgery  and  gen- 
eral practice.  The  first  important  application  of  the  knowledge  of 
germs  was  to  surgery.  Antiseptic  surgery,  originated  by  Lord  Lister, 
has  resulted  in  the  saving  of  untold  thousands  of  lives  and  has  led 
in  turn  to  aseptic  surgery,  which  is  still  more  effective.  Not  only  has 
it  reduced  the  previous  mortality  from  operations,  but  it  has  vastly 
increased  the  number  and  kind  of  operations  which  can  be  performed 
in  cases  which  under  the  old  regime  would  necessarily  have  proved 
fatal. 

Of  one  of  the  most  recent  advances  the  eminent  surgeon  Dr.  W.  J. 
Mayo  writes : 

Second  only  to  the  germ  theory  has  been  the  usefulness  of  the  great  discovery 
of  Rontgen  and  the  application  of  the  X-ray  to  surgical  diagnosis.  It  makes 
certain  the  diagnosis  in  a  large  number  of  conditions  which  were  previously 
a  matter  of  speculation,  and  enables  remedial  surgical  measures  at  an  early 
date,  lessening  mortality  and  morbidity. 

Another  great  surgical  discovery  is  the  suture  of  blood  vessels  evidenced  by 
the  work  of  Carrel.  Its  possibilities  are  astounding.  The  ability  to  transplant 
the  kidney  of  one  dog  to  another  and  have  it  continue  its  function,  the  amputa- 
tion of  a  leg  and  its  resuture,  opens  up  the  whole  question  of  the  transplantation 
of  sound  for  diseased  organs,  especially  organs  which  are  doubIe.<* 

In  these  and  other  surgical  work  a  certain  amount  of  vivisection  is 
necessary.  The  present  outcry  against  vivisection  is  an  example  of  a 
defective  sense  of  _  proportion.  While  needless  cruelty  should  be 
avoided,  the  suffering  of  animals  through  vivisection,  including  all 
cases  where  the  practice  has  been  abused,  is  as  nothing  compared  with 
the  suffering  of  human  beings  which  would  be  caused  if  all  vivisection 
were  abolished. 

"  Letter  from  Dr.  William  J.  Mayo. 


66  EEPOET   ON    NATIONAL  VITALITY. 

The  progress  of  antisepsis  has  so  reformed  midwifery  that  puer- 
peral fever,  a  former  scourge  of  humanity,  is  now  extremely  rare. 
In  many  cases  the  child,  by  being  freed  from  gonorrheal  contamina- 
tion by  the  mother  at  birth,  has  been  saved  from  blindness."^ 

The  advance  of  surgery  is  shown  by  the  following  table  of  mor- 
tality of  the  wounded  in  the  wars  of  the  nineteenth  century.  Anti- 
septic surgery  was  introduced  at  the  time  of  the  Franco-Prussian 
war  in  1870-1 : 

Per  cent. 

Crimean  war,  English  troops 15.  2 

French  troops  in  Italy,  1859-60 37.4 

German  army,  1870-71 11. 1 

Spanish-American,  1898 6.  6 

Transvaal,  1900-1901 5.  5 

In  general  practice  progress  is  also  being  made.  The  use  of  violent 
drugs  is  fast  going  out  of  fashion.  The  recognition  of  the  self-limit- 
ing character  of  most  of  the  acute  diseases  sounded  the  death  knell 
of  the  harsh  drugging  of  the  olden  time.  Laboratory  experimenta- 
tion and  careful  study  as  to  the  physiologic  and  theraj)eutic  effects 
of  drugs  have  shown  the  necessity  of  subjecting  everything  material 
or  immaterial,  intended  for  the  relief  of  human  ailments,  to  the 
crucible  of  the  most  rigid  scientific  scrutiny.  This  sentiment  has 
grown  until  in  the  best  medical  circles  it  is  properly  considered  a 
reproach  for  a  physician  to  use  any  preparation  without  an  exact 
knowledge  of  its  composition  and  a  definite  conception  of  the  results 
expected  from  its  administration.  The  number  of  medicines  used  by 
physicians  is  decreasing  and  will,  if  the  predictions  of  experts  in  this 
field  may  be  trusted,  ultimately  be  reduced  to  a  small  fraction  of  the 
present  pharmacopoeia.  Many  medicines,  like  quinine  and  mercury/ 
will  of  course  merit  a  continuance  of  use.  Syphilis,  malaria,  hook- 
worm disease,  and  some  other  diseases  are  best  combated  by  drugs. 

Serum  therapy,  although  in  its  infancy  as  to  most  diseases,  has 
opened  up  a  field  of  great  promise.  For  example,  antidiphtheritic 
serum,  the  one  best  understood  and  in  most  conmion  use,  has  reduced 
the  mortality  in  that  disease  from  50  or  60  to  12  or  14  per  cent.^  Not 
so  much  medicines  or  serums,  but  hygiene,  will  probably  be  the  de- 
pendence of  the  next  generation  of  physicians.  Possibly  the  term 
"  medicine  "  will  some  day  be  almost  as  inappropriate  in  describing 
the  treatment  toward  which  physicians  are  tending  as  the  term 
"  leech  "  now  is  in  describing  the  physician.  The  profession  has 
ceased  to  be  hostile  to  hygienic  treatment,  and  is  slowly  but  surely 
substituting  it  for  much  of  the  internal  treatment  formerly  employed. 
The  new  treatment  includes  the  use  of  air,  light,  water,  food,  rest, 
massage,  mechanical  vibration,  electricity,  exercise,  and  suggestion, 
under  the  names  of  aerotherapy,  hydrotherapy,  psychotherapy,  etc. 
These  remedies  have  the  great  advantage  of  preventing  as  well  as 
curing  disease. 

It  onl}''  remains  for  all  medical  schools  and  the  courses  of  lectures 
now  gratuitously  provided  by  the  American  Medical  Association  for 
all  county  medical  societies  to  teach  these  things  in  such  a  thorough 
and  practical  way  as  will  reach  the  whole  profession  and  bring  these 

oElie  Metchnikoff,  "The  Nature  of  Man,"  New  York  (Putnam),  1903,  p.  210. 
6  Metchnikoff,  "  The  Nature  of  Man,"  p.  212. 


EEPORT   ON    NATIONAL  VITALITY.  67 

benefactions  to  the  whole  people.  In  proportion  as  prevention  is 
more  important  than  cure,  tlie  rapid  advance  in  the  knowledge  and 
practice  of  preventive  medicine  will  be  of  value. 

"  To  hygiene  belongs  without  a  doubt  the  place  of  honor  in  modern 
medicine.  It  is  in  the  prevention  of  infectious  diseases  that  the  inter- 
est of  the  medical  art  is  now  mainly  centered."  ^  The  best  men  are 
turning  to  these  physiologic  methods  with  enthusiasm.*  They  are 
learning  to  take  into  account  the  anxiety  and  other  mental  reactions 
of  the  patient  as  to  what  is  said  in  his  presence."  They  are  becoming 
more  public-spirited  and  cooperative,'^  and  alive  to  their  responsibil- 
ity to  set  patients  a  good  example  in  living  hygienic  lives.^ 

The  trend  toward  prevention  is  indicated  in  various  ways — by  the 
fact,  for  instance,  that  some  physicians  are  now  employed  by  families, 
schools,  firms,  associations,  etc.,  for  the  purpose  chiefly  of  preventing 
rather  than  curing  disease.  Women  dentists  graduating  from  the 
University  of  Michigan  have  made  a  practice  of  attending  to  chil- 
dren's teeth  at  a  stated  amount  per  month.  Employers  are  increas- 
ingly securing  the  services  of  competent  physicians  to  care  for  the 
health  and  physical  welfare  of  their  employees.  This  is  a  preventive 
measure,  and  has  been  found  to  be  a  "  paying  proposition  "  to  the 
employer  because  of  the  resulting  enlarged  efficiency  of  the  workers. 

Their  modern  fight  against  tuberculosis  has  led  physicians  to  a 
larger  use  of  fresh  air  in  their  practice.  At  first  many  employed  this 
agent  merely  as  a  "  specific  for  tuberculosis,"  but  its  utility  in  all 
chronic  ailments,  such  as  neurasthenia,  for  instance,  was  next  recog- 
nized. Latterly,  fresh  air  has  been  discovered  to  be  of  use  in  pneu- 
monia and  other  acute  diseases.  It  is  now  not  unusual  to  find  physi- 
cians advising  their  patients,  whether  ill  or  well,  to  sleep  out  of  doors. 
There  can  be  no  question  that  man  was  originally  an  outdoor  animal. 

The  discovery  of  the  germ  origin  of  Asiatic  cholera,  tuberculosis, 
diphtheria,  typhoid  fever,  bubonic  plague,  influenza,  and  other  dis- 
eases, and  of  the  part  played  by  water,  impure  food,  insects,  rodents, 
and  other  common  and  almost  omnipresent,  but  hitherto  unrecognized, 
agencies  as  carriers  of  disease  to  man  and  animals,  has  awakened  a 
world-wide  interest  in  these  subjects  which,  properly  fostered  and 
directed,  opens  up  ever  extending  possibilities  to  the  humanitarian, 
the  economist,  the  statesman,  and,  still  more,  to  the  people  at  large. 

The  consequence  must  be  a  great  revolution  in  medicine  in  the  im- 
mediate future.  The  practice  of  medicine  is  destined  to  become  a 
much  more  powerful  agent  than  ever  before  in  the  suppression  and 
prevention  of  disease.  This  result  will  be  reached  when  the  change 
now  going  on  permeates  the  rank  and  file  of  the  profession.  It  would 
be  a  pity  if,  through  undue  conservatism  of  some  of  its  members,  the 
profession  should  lose  some  of  its  prestige  hard  won  during  the  last 
generation.  Already  the  ever-present  quack  is  pressing  into  the  invit- 
ing field.     As  the  public  demands  "  drugless  treatment "  and  many 

"Metchnikoff,  "The  New  Hygiene,"  Chicago  (Keener),  1906,  pp.  12-13. 

6  See  G.  Stanley  Hall,  "Adolescence,"  New  York  (Appleton),  1905,  vol.  1, 
p.  238. 

c  See  A.  T.  Schofield,  "Power  of  Mind,"  London  (Churchill),  1902,  2d  ed., 
p.  277. 

^  See  Osier,  "  Maryland  Medical  Journal,"  October,  1905,  p.  420. 

^  See  Professor  Osier's  address  to  St.  Mary's  Hospital,  London,  1907. 


68  TIEPOET    ON    NATIONAL   VITALITY, 

physicians  fail  to  see  and  meet  that  demand  so  far  as  it  is  rational, 
the  quacks  see  their  opportunity.  As  a  consequence,  there  is  fast 
developing  a  species  of  quack  that  not  only  does  not  use  "  patent 
medicines,"  but  condemns  their  use  by  regular  physicians.  Men  of 
this  type  base  their  appeals  on  "  naturopathy,"  become  "  food  ex- 
perts," prescribe  fasting,  or  two  meals  a  day  or  five  meals  a  day,  give 
lessons  in  "  deep  breathing,"  conduct  outdoor  sanatoria,  and  employ 
light  and  air  baths,  dry  cupping,  mechanical  vibration,  intestinal 
lavage,  Avater  cures,  electricity,  osteopathic  manipulations,  "  divine 
healing,"  etc.  All  these  methods  have  value  under  certain  conditions ; 
the  only  objection  is  that  when  applied  by  the  uneducated  they  are 
utilized  to  poor  advantage.  The  fault  lies  not  in  the  therapeutic 
means  but  in  those  who  use  them.  Physicians  sometimes  confuse  the 
two,  and  make  the  mistake  of  opposing  the  means  and  user  alike. 
They  reject  good  means  of  cure  because  employed  by  "  irregulars." 

The  result  is  that  the  patient  sometimes  finds  the  best  means  of 
recuperation  in  the  hands  not  of  medical  men,  but  of  uneducated 
"physical  trainers."  The  public  will  go  and  should  go  to  those 
who  will  render  the  most  effective  help.  In  order  that  the  medical 
profession  may  suppress  quackery  the  way  must  be  not  to  oppose 
the  use  of  beneficial  therapeutic  agents  in  incompetent  hands,  but 
to  get  their  use  into  competent  hands  by  adopting  them  them- 
selves. There  is  a  quackery  that  is  villainous  and  injurious.  This 
should  be  suppressed.  But  there  is  another  quackery  which  is 
well  intentioned  and  which,  in  spite  of  ignorance,  manages  to  do 
some  good.  The  good  in  it  should  be  appropriated  by  the  profession. 
By  always  promptly  absorbing  the  best  the  profession  will  be  in  a 
position  to  cast  out  the  worst  in  "  irregular  "  systems  of  therapeutics. 
It  may  then  recover  the  ground  which  it  has  too  often  lost.  There 
was  no  reason  why  it  should  have  lost  hundreds  of  thousands  of 
patients  to  "  Christian  Science,"  except  that  these  patients  were  for 
the  most  part  benefited,  and  greatly  benefited,  by  Christian  Science 
after  having  received  no  benefit,  and  often  injury,  from  the  profes- 
sion. "  Easily  physicians,  without  knowing  it,  can  produce  sickness 
by  pessimistic  prophecies,  by  anxious  looks  or  words.  Thus  are 
diseases  suggested  (unconsciously)  by  the  physician." '^  Had  the 
profession  made  use  of  mental  therapeutics  not  only  could  they  have 
saved  themselves  the  enmity  of  these  hundreds  of  thousancls,  but 
they  could  have  nipped  in  the  bud  the  crude  metaphysics  which 
teaches  the  nonexistence  of  disease  and  death  and  the  uselessness  of 
any  therapeutic  agent  except  those  employed  by  the  promulgator. 
The  example  of  so-called  "  Christian  Science  "  is  only  one  of  several 
protests,  more  or  less  misguided,  against  the  present  practice  of 
medicine. 

Had  all  or  most  members  of  the  profession  conceded  long  ago  the 
harmfulness  of  many,  if  not  most,  violent  drugs  it  might  have  fore- 
stalled the  present  antidrug  movement  among  the  laity.  The  mis- 
guided antivaccination  movement  is  simply  the  carrying  to  extremes 
of  the  antidrug  movement. 

The  Greeks  were  probably  the  most  hygienic  people  that  ever  lived 
and  they  knew  nothing  of  modern  scientific  medicine,  not  even  of 
the  circulation  of  the  blood.    This  shows  that  man's  primitive  knowl- 

o  Schofield,  loc.  cit.,  pp.  215-216. 


KEPORT    ON    NATIONAL   VITALITY.  69 

edge  or  instincts  may  be  sufficient  to  enable  him  to  keep  and  develop 
health. 

The  old  code  of  medical  ethics,  though  well-intentioned,  was  so 
inelastic  and  was  so  susceptible  of  misconstruction  as  often  to  block 
the  way  to  progress.  The  magnitude  and  far-reaching  effects  of  this 
evil  were  long  ago  recognized  by  leading  minds  in  the  profession,  and 
after  years  of  agitation  such  a  revision  was  unanimously  agreed  upon 
in  1903  as  makes  the  modern  principles  of  medical  ethics  purely 
advisory  and  far  more  liberal  than  formerly.  All  restrictions  as  to 
consultations  were  removed,  medical  societies  were  thrown  open  to 
reputable  physicians  of  every  school  of  practice  requiring  scientific 
training,  and  agencies  put  in  operation  for  such  organization  and 
cooperation  and  to  encourage  such  liberty  of  individual  opinion  as 
is  demanded  by  the  spirit  of  the  age.  Under  the  most  active  efforts 
of  the  medical  schools,  societies,  and  journals  it  will  doubtless  require 
years  of  time  for  this  liberal  spirit  to  reach  all  members  of  the  pro- 
fession to  the  extent  which  is  so  desirable.  But  when  this  is  done  and 
when  the  public  can  be  made  to  understand  that  it  has  been  done  the 
prejudice  which  has  hampered  the  profession's  usefulness,  which  has 
made  it  so  difficult  to  secure  and  enforce  health  and  medical  legisla- 
tion necessary  for  the  protection  of  the  highest  interests  of  the  people, 
and  which  has  so  fostered  and  given  opportunity  for  quackery,  will 
gradually  become  ancient  history. 

A  frequent  lay  comment  on  some  members  of  the  medical  pro- 
fession is  that  to  be  true  teachers  of  health  they  must  practice  what 
they  preach.  A  physician  can  not  succeed  in  controlling  drug  habits 
or  alcoholism  if  he  has  these  habits  himself.  He  can  not  fight  "  patent 
medicines  "  if  he  uses  them  himself."  He  can  not  effectively  fight  the 
social  evil  if  he  himself  practices  abortion.  The  standards  of  the 
profession  are  high.  It  is  the  individual  who  is  at  fault.  A  clergy- 
man who  preaches  purity  from  the  pulpit  while  living  a  double  liie 
is  disgraced.  In  the  same  way,  now  that  physicians  are  assuming 
the  function  of  giving  instruction  in  orthobiosis  and  hygiene,  they 
are  being  called  to  account  for  their  own  daily  lives.  Self-interest 
and  altruism  alike  will  lead  to  needed  corrections.  The  physician  in 
these  days  of  preventive  medicine  should  keep  himself  well.  The 
challenge  "  Physician,  heal  thyself  "  is  being  followed  by  the  challenge 
"  Keep  thyself  well."  Example  more  than  precept  is  a  principle  to 
be  applied  here  as  elsewhere.  He  can  not  induce  his  patients  to  diet 
or  take  exercise  if  he  himself  is  addicted  to  the  fleshpots  and  the  easy 
chair.  Many  a  physician  to-day  loses  patients  because  he  and  his 
family  are  on  the  sick  list,  or  because  as  a  man  he  practices  habits 
which  as  a  physician  he  does  not  approve. 

The  physicians  in  this  country  now  number  about  130,000.  Their 
calling  is  in  some  respects  the  noblest  in  the  world  to-day.  During 
the  present  generation  the  profession  has  begun  to  be  appreciated  for 
its  great  services  to  public  and  private  health  and  for  its  self-sacrifice, 
which  is  unequaled  in  any  other  profession  except  the  ministry.  It 
has  now  before  it  an  opportunity  such  as  never  before  existed.  Those 
of  us  who  believe  in  its  mission  look  forward  to  incalculable  blessings 
to  suffering  humanity  from  greater  knowledge  better  applied. 

"  See  A.  Jacobi,  Journal  American  Medical  Association,  September  29,  1906, 
p.  978. 


70  KEPOET   ON   NATIONAL  VITALITY. 

Section  3. — Institutional   hygiene. 

The  large  cities  have  established  special  contagious  hospitals,  where 
prompt  isolation  of  infectious  casee  may  be  enforced.  The  decrease 
of  tuberculosis  may  be  traced  largely  to  hospital  isolation.*^  Leprosy 
ivas  the  first  disease  to  be  quarantined  *  and  its  virtual  disappearance 
in  civilized  countries  has  been  due,  at  least  in  the  opinion  of  many 
authorities,  to  the  strict  isolation  methods  universally  adopted. 

Of  a  different  kind  is  the  segregation  of  defective  classes  of  the 
community.  This  has  led  to  considerable  conservation  of  their  powers 
and  abilities.  Institutions  for  the  deaf  and  blind  in  the  United  States 
contained  14,700  inmates  in  1904,  and  spent  for  purposes  of  main- 
tenance over  $3,500,000."  In  these  schools  the  deaf  and  dumb  and  the 
blind  are  taught  trades  and  professions,  their  usefulness  being  thus 
much  enlarged. 

The  New  York  state  commission  on  the  blind  recommended  in  1907 
a  state  board  for  the  blind  to  conduct  an  employment  bureau  for  the 
blind  of  that  State,  to  establish  schools,  and  to  put  into  operation 
measures  for  the  prevention  of  blindness.  It  is  pointed  out  that  of  the 
100,000  cases  of  blindness  in  the  United  States  a  great  percentage  is 
traceable  to  disease  and  accident  of  a  preventable  character.  The 
<;ommission  estimates  that  of  1,000  cases  in  New  York,  450  were 
possibly  avoidable  and  325  (or  one- third)  certainly  so. 

For  the  checking  of  insanity  the  crying  need  is  a  study  of  the 
causes  of  the  malady  with  a  view  to  its  prevention.  For,  as  Doctor 
Ditman  remarks,  nine-tenths  of  the  inmates  of  our  insane  asylums  are 
incurable,  according  to  our  present  knowledge.  He  adds :  "  What  an 
argument  for  the  prevention  of  the  disease !  "  ^  Much  may  be  ex- 
pected from  the  Phipps  fund,  for  the  study  of  insanity,  recently 
established  at  Johns  Hopkins  University. 

In  the  first  place,  our  medical  students  should  receive  constant 
clinical  instruction  in  mental  diseases,  particularly  in  their  incipient 
stages.  Almost  equally  important  are  popular  lectures  on  the  pre- 
ventable and  other  causes  of  insanity  given  under  the  auspices  of 
medical  schools  or  local  boards  of  health.  Such  lectures  have  been 
given  in  New  York  and  Boston,  and,  judging  by  the  attendance,  must 
prove  a  valuable  agency  in  diffusing  a  correct  knowledge  of  the  cause 
and  development  of  mental  disease.  In  this  education  of  the  laity 
popular  treatises  on  mental  hygiene  would  prove  most  helpful. 
Such  a  book  as  Doctor  Clouston's  "  Hygiene  of  Mind  "  could,  with 
advantage,  be  placed  in  the  hands  of  every  young  person,  and  might 
even  be  adopted  as  a  text-book  in  high  schools.  Certainly  the  physi- 
ology of  mind  is  as  deserving  of  popular  consideration  as  that  of 
digestion,  respiration,  and  the  circulation. 

By  a  clearer  insight  into  the  beginnings  of  mental  disease,  gained 
through  the  popular  lecture  and  a  nontechnical  literature,  society 
will  become  so  far  enlightened  that  intelligent  personal  prophylaxis 

«  See  Newsholme,  "  Phthisic  death  rate,"  Journal  of  Hygiene,  July,  1906. 
^  See  J.  M.  Eager,  M.  D.,  "  The  early  history  of  quarantine,"  Yellow  Fever 
Institute  Bulletin  No.  12,  pp.  4-5. 

c  Census  report  on  "  Benevolent  institutions,"  1904. 
*  Ditman,  loc.  cit.,  p.  46. 


REPORT    ON    NATIONAL  VITALITY.  71 

may  be  anticipated.*^  A  knowledge  of  danger  is  the  surest  means  of 
guarding  against  it.  "  The  most  obvious  line  of  attack  must  be  in 
the  direction  of  the  four  great  etiological  factors  of  insanity,  heredity, 
alcohol,  syphilis,  and  environment.  Abstractly  considered  these  four 
causes  are  preventable  or  removable."  ^ 

_  As  an  intermediate  step  between  home  and  hospital,  the  sanato- 
rium offers  both  cure  and  prevention.  Many  tuberculosis  sanatoria 
will  take  patients  only  in  the  incipient  and  early  stages  of  the  dis- 
ease. Sanatoria  are  used  by  many  as  places  of  recuperation.  The 
tired  business  man  and  the  nervous  housewife  find  at  the  sanatorium 
the  quiet  they  need,  and  a  week  or  two  of  rest  enables  them  to  escape 
threatened  serious  ills. 

Many  public  institutions,  in  response  to  popular  demand,  are  to- 
day installing  methods  and  equipment  that  are  essentially  prevent- 
ive. More  than  one  department  store  in  the  large  cities"^  filters  its 
air  in  order  that  patrons  and  clerks  shall  not  feel  oppressed  by  vitia- 
tion of  the  atmosphere.  An  indirect  result  is  the  prevention  of  tuber- 
cular and  other  diseases.  A  leading  hotel  in  Philadelphia  has  pitched 
tents  on  its  roof,  where  a  large  colony  of  well  people — not  sick — 
sleep  out  of  doors,  and  the  same  hotel  utilizes  its  roof  in  winter  for 
a  skating  rink.  Mothers'  clubs  are  an  increasing  factor  in  the  spread 
of  a  knowledge  of  hygiene.  Kecently  a  case  came  to  light  of  a  new 
member  of  a  mothers'  club  who  was  feeding  her  6-months-old  baby 
on  sausage,  tea  cake,  etc.,  and  giving  it  drugs  when  she  wanted  to  go 
out.  She  was  greatly  surprised  when  informed  of  the  wrong  she  was 
doing. 

Growing  interest  in  the  science  of  home  economics,  already  re- 
ferred to,  is  an  indication  of  our  increasing  realization  of  the  im- 
portance of  healthful  homes  in  the  community.  While  the  number 
of  .schools  and  colleges  which  offer  courses  in  higher  domestic  science, 
and  in  what  might  be  called  "  true  home  economics,"  is  growing,  they 
are  nevertheless  still  comparatively  few.  More  teachers  should  be 
equipped  with  scientific  knowledge  regarding  modern  sanitation  in 
order  that  they  may  give  practical  courses  in  grammar  and  high 
schools,  and  higher  instruction  should  include  the  topics  of  hygiene 
and  sanitation.  Home  making  may  be  studied  in  many  details,  such 
as  the  construction  of  healthful  houses,  the  purification  of  food  and 
water  supplies,  and  the  cleansing  of  cities,  whereby  the  enlistment  of 
both  boys  and  girls  in  all  lines  of  home  and  lyunicipal  hygiene  can 
be  secured. 

The  churches  are  now  joining  in  the  health  movement.  The  lead 
has  been  taken  by  the  Eev.  Elwood  Worcester  and  Rev.  Samuel 
McComb  at  the  Emanuel  Church  in  Boston.  Trained  physicians 
are  employed  for  diagnosis  and  for  general  advi'^^,  but  great  em- 
phasis is  laid  on  the  power  of  suggestion  and  of  (jhristian  self-con- 
trol over  bodily  ills.  The  object  is  to  get  both  patient  and  physician 
to  stop  "  thinking  sick  and  talking  sick,"  as  Doctor  Goler  has  put  it. 

oA  book  which  brings  the  subject  home  with  unusual  force  to  the  ordinary 
reader  is  an  autobiographical  sljetch  by  a  recovered  patient,  "A  Mind  that 
Found  Itself."  by  Clifford  W.  Beers,  New  York  (Longmans,  Green),  190S. 

*  Charles  P.  Bancroft,  M.  D.,  "  Hopeful  and  discouraging  aspects  of  the  psy- 
chiatric outlook,"  address  at  meeting  of  American  Medico-Psychological  Asso- 
ciation, Cincinnati,  1908. 

84369— No.  30—09 6 


72  REPOET   ON   NATIOITAL  VITALITY. 

Section  4. — School  hygiene. 

In  every  progressive  country  to-day  the  hygiene  of  school  life  is 
coming  to  be  regarded  of  paramount  importance.  At  the  Inter- 
national Congress  on  School  Hygiene,  in  London,  August  5-10,  1907,'^ 
there  were  in  attendance  at  least  500  delegates,  representing  the  gov- 
ernments of  the  world  and  societies  devoted  to  the  advancement  of 
human  welfare,  and  in  addition  there  were  1,500  individuals  inter- 
ested in  the  improvement  of  the  health  of  school  children  and  all 
that  this  implies.  The  fact  was  brought  out  at  the  congress  that 
European  countries,  notably  Switzerland,  Germany,  France,  _  Eng- 
land, and  Scotland,  are  doing  more  than  the  United  States  in  the 
medical  inspection  of  scliools  and  that  they  are  seemingly  making 
plans  for  the  improvement  in  every  direction  of  the  hygienic  con- 
ditions of  school  life.^  Even  in  Italy  the  leading  statesmen  are  ap- 
parently convinced  that  the  matter  of  chief  importance  at  the  present 
moment  in  their  educational  work  is  to  place  it,  from  start  to  finish, 
upon  a  hygienic  basis.'' 

It  is  the  unanimous  opinion  of  all  students  of  the  matter  that  the 
neglect  of  the  hygiene  of  school  life  in  the  larger  sense  is,  first  of  ally 
more  or  less  disastrous  to  a  considerable  proportion  of  the  pupils.<^ 
With  us,  as  well  as  in  most  European  countries,  children  are  com- 
pelled by  the  state  to  attend  school  for  a  number  of  years.  Many 
of  them  suffer  constantly  from  defective  vision,  hearing,  and  respira- 
tion, from  nervous  overstrain,  and  from  other  ailments  which  are 
greatly  aggravated  by  the  confinement  and  stress  of  school  life.® 
Pupils  are  always  exposed  to  infectious  diseases.  It  is  no  unusual 
thing  in  our  country  to  see  a  contagious  disease  sweep  through  a 
whole  school  so  rapidly  that  the  local  board  of  health  can  hear  of  it 
and  order  the  school  closed  only  after  the  harm  has  been  done. 

Great  as  is  the  injury  done  by  the  spread  of  infectious  diseases  to 
children  thus  massed  together  in  schools,  the  injury  resulting  from 
imperfect  seating,  lighting,  ventilation,  and  sanitation  of  school 
buildings  is  still  more  serious.  In  every  part  of  our  country,  as 
well  as  in  the  progressive  countries  of  Europe,  those  familiar  with 

OS  The  proceedings  of  the  congress  contain  papers  by  distinguished  physicians 
and  educators  upon  every  phase  of  the  hygiene  of  school  life.  Existing  evils 
are  pointed  out  and  remedies  suggested.  Summaries  of  the  papers  may  be 
found  in  the  Nineteenth  Century,  September,  1907,  pp.  388-394. 

*  In  addition  to  papers  presented  at  the  International  Congress  on  School 
Hygiene,  see  the  following:  A  series  of  articles  in  the  School  Review  (Univer- 
sity of  Chicago)  for  1907,  by  Prof.  Hermann  Schwartz,  entitled  "The  study  of 
experimental  pedagogy  in  Germany."  Many  articles  in  the  magazine  Zeit- 
schrift  fur  Schulgesundheitspflege  show  the  great  interest  in  Germany  in  school 
hygiene.  Professor  Binet,  of  Paris,  has  established  a  laboratory  for  the  study 
of  childhood  in  relation  to  educational  work,  and  he  will  give  particular  at- 
tention to  problems  concerning  physical  defects  and  mental  and  moral  short- 
comings. For  other  such  institutions  see  The  Psychological  Bulletin,  Vol.  VI^ 
March  15,  1909,  pp.  84-103. 

'^  See,  for  example.  Professor  Garlanda's  "II  Terzia  Italia,"  in  which  he 
shows  the  only  way  in  which  Italy  can  regain  her  old-time  vigor  and  efficiency. 

•^See  M.  V.  O'Shea:  "Dynamic  Factors  in  Education,"  New  York  (Mac- 
millan),  1906,  Part  II,  where  the  whole  subject  is  discussed. 

e  See  Oppenheim :  "  The  development  of  the  child,"  Chap.  V.  Also  Tyler  r 
"Growth  and  education;"  Burbank:  "The  training  of  the  human  plant;'' 
Burk :  "  From  fundamental  to  accessory,"  etc. ;  Pedagogical  Seminary,  Vol.  VL 
Krgeplin:  "A  measure  of  mental  capacity,"  Popular  Science  Monthly,  vol.  49. 


KEPORT   ON    NATIONAL  VITALITY.  73 

the  situation  are  appealing  most  urgently  for  improvement  in  the 
physicial  basis  of  education.  This  is  not  the  place  to  recite  the  dis- 
abilities which  are  said  by  men  competent  to  speak  on  the  subject 
to  result  from  keeping  children  for  at  least  eight  years  in  confinement 
and  at  hard  mental  labor  under  conditions  that  waste  their  vitality 
and  develop  bodily  defects  and  habits  prejudicial  to  health.  The 
list  of  such  disabilities  is  a  long  and  impressive  one.**  Unfortunately, 
we  do  not,  as  a  people,  sufficiently  appreciate  that  the  character  of 
social  life  with  us  is  changing  rapidly,  and  that  consequently  our 
children  are  particularly  susceptible  to  certain  diseases  and  defects; 
to  wit,  those  arising  from  the  adoption  of  an  indoor  life  of  compara- 
tive muscular  inactivity,  with  greatly  increased  demands  made  upon 
particular  organs,  such  as  the  eyes  and  the  brain. 

Doctor  Cronin,  of  New  York,  maintains  that  in  a  school  population 
of  650,000,  30  per  cent  of  the  children  were  from  one  to  two  years 
behind  their  proper  class.  Ninety-five  per  cent  of  these  backward 
children  were  so  principally  because  of  defects  of  eye,  ear,  nose,  or 
throat,  which  could  easily  be  detected  and  remedied  through  effective 
medical  inspection.  Experiments  at  home  and  abroad  have  proven 
beyond  any  doubt  that  the  majority  of  children  of  this  sort,  when 
given  proper  medical  treatment,  improve  markedly  in  intellect  and 
general  conduct.  The  State  attempts  to  educate  these  children,  but 
its  effects  are  to  a  large  extent  wasted.  Doctor  Osier  calculated 
that  in  the  special  city  to  which  reference  has  been  made  there  was, 
on  account  of  a  lack  of  medical  supervision  of  educational  work,  a 
yearly  financial  loss  of  $1,666,666 ;  and  of  course  the  loss  which  came 
from  moral  deviation  due  to  defective  physical  functioning  was  of 
far  greater  importance.  Doctor  Osier  said  recently,  in  effect,  that 
he  considered  it  of  greater  importance  to  the  nation  that  the  question 
of  sound  teeth  be  intelligently  considered  than  that  the  consumption 
of  alcohol  be  restricted,  important  as  the  latter  problem  is.  In  similar 
vein.  Doctor  Newton  reports  a  case  of  an  old,  unhygienic  school  build- 
ing in  a  small  town  being  fitted  up  with  a  ventilating  system,  with 
the  result  that  the  cost  of  the  improvement  was  saved  in  a  short  time 
in  salaries  that  otherwise  would  have  been  paid  to  extra  teachers  for 
taking  the  place  of  those  made  sick  by  the  foul  air  in  the  building. 

We  now  know  the  major  effects  at  least  on  intellect  and  tempera- 
ment of  sense  defects,  adenoids,  decaying  teeth,  and  minor  physical 
deformities;  and  we  also  know  how  such  deviation  from  normality 
can  be  readily  and  inexpensively  detected  and  remedied,^  but  there 
are  whole  States  where  no  advantage  whatsoever  is  taken  of  this 
knowledge,  and  in  practically  every  State  in  the  country  there  are 
communities  in  which  absolutely  no  attention  is  paid  to  any  of  these 
matters.  The  people  go  on  in  traditional  ways,  trusting  to  luck  and 
disregarding  the  changes  taking  place  in  society. 

"See  Shaw:  "School  hygiene;"  Keating:  "Mother  and  child;"  Ballantyne, 
in  the  Lancet,  Vol.  2,  1890 ;  Bancroft :  "  Physical  Education  Review,"  Vol.  VII ; 
Howe,  "  The  lighting  of  schoolrooms ;  "  Burrage  and  Bailey :  "  The  Sanita- 
tion and  decoration  of  school  buildings."  The  Magazine  of  School  Hygiene, 
published  under  the  direction  of  the  School  Hygiene  Association,  contains  in 
each  issue  articles  showing  the  evils  resulting  from  unhygienic  conditions  in  the 
schools. 

^  See,  for  example,  two  books  by  Doctor  Warner,  of  London :  "  The  Study  of 
Children  "  and  "  The  Nervous  System  of  the  Child."  The  city  of  Chicago  main- 
tains a  department  for  the  study  of  backward  and  defective  children  in  the 
public  schools. 


74 


BEPOKT   ON   NATIONAL  VITALITY. 


The  health  of  our  school  children,  then,  should  be  conserved  by  a 
system  of  competent  medical  inspection  <»  which  should  secure  the 
correction  of  defects  of  eyes,  ears,  teeth,  as  well  as  defects  due  to 
infection  or  malnutrition.     In  Europe — 

all  the  investigations  disclosed  an  astonishing  amount  of  ill  health  among 
school  children;  and  though  the  variations  from  the  normal  were  found  to 
differ  in  degree,  they  were  on  every  hand  alike  in  kind.  In  nearly  every 
Instance  they  were  more  pronounced  in  girls  than  in  boys,  and  were  often  most 
manifest  in  scholars  of  the  better  social  classes.  Thus  there  were  discovered 
the  following  percentages  of  morbidity  among  school  boys:  In  Great  Britain, 
20;  in  Denmark,  29;  in  Germany,  30;  in  Copenhagen,  31;  and  in  Sweden,  37. 
The  percentages  noted  among  the  girls  were:  In  Great  Britain,  16;  in  Copen- 
liagen,  39;  in  Denmark,  41;  in  Lausanne,  43;  in  Germany,  50;  and  in 
Stockholm,  62— an  average  morbidity  for  boys  of  29  and  for  girls  of  42  per 
cent.^ 

Similar  results  have  been  reached  in  certain  cities  of  the  United 
States.  A  "  committee  on  the  physical  welfare  of  school  children  " 
in  New  York  City  examined  New  York  school  children  and  found 

that  «— 

66  per  cent  needed  medical  or  surgical  attention  or  better  nourish- 
ment. 

40  per  cent  needed  dental  care.*^ 

38  per  cent  had  enlarged  glands  of  the  neck. 

SI  per  cent  had  defective  vision. 

18  per  cent  had  enlarged  tonsils. 

10  per  cent  had  postnasal  growths. 

6  per  cent  were  undernourished. 

Dr.  Walter  Cornell  has  been  making  an  extensive  study  of  eye 
strain  among  school  children.    These  were  his  findings : « 

The  relationship  of  poor  vision  to  scholarship  was  studied  in  219  children. 
As  will  be  noticed,  the  difference  in  marks  between  those  with  normal  and  those 
with  bad  vision  is  greatest  in  arithmetic  and  spelling,  which  studies  require 
more  extensive  use  of  the  blackboard. 

ScholarsMp  percentages  obtained. 


Children  with- 

Arith- 
metic. 

Geogra- 

Spelling. 

Average. 

79 
70 
66 

69 
71 
70 

76 
77 
71 

75- 

73+ 

69 

in  New  York  City  29.5  p,er  cent  of  79,069  children  examined  suffered  from 
defective  vision.     In  London  26  per  cent  of  20,000  children  examined  by  eight 

°'  See  Gulick  and  Ayres.  "  Medical  Inspection  of  Schools,"  Russell  Sage 
foundation  Publication,  New  York,  190S ;  see  also  "  The  Psychological  Clinic," 
especially  Vol.  ii,  No.  8. 

*  G.  Woodruff  Johnson,  M.  D.,  "  Effects  of  school  life  on  children's  health," 
ISforth  American  Review,  vol.  1S2,  p.  8.31. 

«Ditman,  loc.  cit,  p.  41. 

^  This  seems  a  low  estimate  in  spite  of  the  fact  that  it  does  not  include  all 
•cases  of  decayed  teeth,  but  only  those  that  have  been  neglected.  See  Dr.  William 
R.  Woodbury,  "  The  People's  Disease :  How  to  Prevent  it,"  Boston  Medical  and 
Surgical  Journal,  March  26,  1908. 

«  "  Backward  Children  in  the  Public  Schools,"  Philadelphia  (Davis),  1908,  p.  7. 


KEPORT   ON    NATIONAL  VITALITY.  75 

ophthalmologists  had  defective  vision,  and  of  this  number  12.5  per  cent  suffered 
from  vision  of  one-half  or  less.  The  author  examined  personally  1,150  children 
and  found  34  per  cent  vpith  defective  vision,  and  of  this  number  G  per  cent 
with  vision  one-half  or  less.  A  small  proportion  of  this  number  only  is  fitted 
with  glasses.  The  rest  suffer  fi-om  real  eye  strain.  The  fault  of  this  deplorable 
condition  is  divided  among  physicians,  school-teachers,  and  parents.  Ignorance 
of  the  existing  facts,  indifCerence,  and  poverty  are  the  real  factors  to  be  dealt 
with. 

Eye  strain  is  the  chief  source  of  the  functional  diseases  of  our  citizens.  It 
begins  in  early  childhood  and  continues  until  senility  is  complete.  It  is  bound 
to  occur  in  every  individual  some  time  in  his  life,  to  a  greater  or  less  degree^ 
It  is  almost  tlie  sole  cause  of  headache,  migraine,  sick  headache,  the  most  fre- 
quent and  habitually  morbidizing  of  human  diseases.  It  is  the  frequent  cause 
of  gastric  and  digestional  diseases  and  of  nervous  and  mental  diseases.  With 
ocular  function  it  conditions  the  origin  of  spinal  curvature,  either  directly  or 
indirectly,  through  the  pathogenic  writing  posture.  Lateral  spinal  curvature, 
the  effect  of  visual  function,  becomes  a  new  secondary  source  of  multifarious 
morbidities,  such  as  neurasthenia,  pelvic  diseases,  hysteria,  etc.  •  It  has  been 
demonstrated  that  27  per  cent  of  European  school  children  have  lateral  spinal 
curvature  at  the  age  of  14,  and  I  have  proved  that  at  least  70  per  cent  of  our 
own  16  to  18  year  old  young  men  of  the  educated  classes  have  this  disease. 
Surprise  at  the  fact  will  soon  become  horror  at  the  national  and  social  tragedy 
which  these  true  figures  indicate.*^ 

Investigations  in  other  cities  and  States  ^  have  shown  similar  re- 
sults, in  view  of  which  it  is  a  conservative  statement  to  say  that  from 
one-half  to  two-thirds  of  our  school  children  need  medical  treatment 
of  some  sort. 

At  least  one  year  in  each  division  of  schooling,  elementary,  secondary,  and 
collegiate,  is  lost  to  the  majority  of  students  because  of  unnecessary  sickness 
or  dullness  caused  by  improper  living." 

That  physical  defects  are  responsible  for  much  of  the  backwardness 
of  children,  and  for  a  large  share  of  truancy  and  incorrigibility,  is  the 
opinion  of  many  educators.'^  In  order  to  correct  physical  abnormali- 
ties and  thereby  to  hasten  mental  and  moral  progress  in  school  life,  a 
number  of  cities  have  instituted  medical  inspection  of  schools. 

So  far  as  inquiry  has  been  able  to  discover,  there  were  in  the  month  of 
June,  1908,  70  cities  in  the  United  States,  outside  of  Massachusetts,  having 
some  form  of  medical  inspection  of  schools.  In  the  State  of  Massachusetts  32 
cities  and  321  towns  had  systems  more  or  less  complete.  It  is  at  present  impos- 
sible to  compute,  or  even  to  closely  conjecture,  how  many  children  these  systems 
reach  at  the  present  time.  It  is  entirely  certain  that  they  do  not  reach  all  of 
the  children  in  the  schools  of  those  cities  and  towns  where  systems  of  medical 
inspection  are  actually  or  nominally  in  operation.^ 

New  York  City  employs  150  physicians,  who  visit  each  public  school  once  a 
day,  shortly  after  9  o'clock,  to  examine  those  children  set  aside  by  the  teacher 

°-  Letter  from  Dr.  George  M.  Gould,  who  perhaps  more  than  any  other  Amer- 
ican has  emphasized  the  evils  of  eye  strain. 

*  See  an  article  by  Prof.  M.  V.  O'Shea  in  the  World's  Work,  Vol.  V,  in  which 
the  results  of  extensive  investigations  were  given.  See  also  Dr.  W.  B.  Drum- 
mond :  "An  introduction  to  child  study,"  Chs.  IX  and  X,  "  Report  of  Conference 
of  State  Sanitary  Officers  of  New  York,"  Buffalo,  October,  1907,  and  various 
Baltimore  and  New  York  City  school  reports. 

'^  Letter  from  Mrs.  Ellen  H.  Richards. 

^  See  O'Shea :  "  When  character  is  formed,"  Popular  Science  Monthly,  Vol. 
LI ;  Rowe :  "  Physical  nature  of  the  child,"  Chs.  9,  10,  13,  14 ;  Scott :  "  Sacrifice 
of  the  eyes  of  school  children,"  Popular  Science  Monthly,  October,  1907 ;  Gould : 
"  The  cause,  nature,  and  consequences  of  eye  strain,"  Popular  Science  Monthly, 
December,  1905 ;  Travis :  "  The  Young  Malefactor,  a  Study  in  Youthful  Degen- 
eracy ;  "  Swift :  "  Mind  in  the  making,"  Chs.  IV  and  V ;  Tanner :  "  The  child," 
Ch.  Ill ;  Kirkpatrick :  "  Fundamentals  of  child  study,"  Ch.  XVII. 

^  Letter  from  Dr.  Luther  H.  Gulick. 


76  KEPOET   ON   NATIONAL  VITALITY. 

as  requiring  attention.  Cliicago  employs  nearly  100  physicians  to  visit  her 
public  schools.  In  Chicago  during  the  ten  months  of  the  school  year  ended 
June  26,  190S,  the  medical  inspectors  of  schools  examined  406,919  pupils." 

And  one  health  officer,  Doctor  Chapin,  of  Providence,  has  even 
established  a  special  fresh-air  school  for  children  who  suffer  from 
certain  forms  of  tuberculosis  or  who  come  from  tuberculous  families. 
He  says  concerning  it : 

Our  fresh-air  school  has  only  been  running  since  last  January  (1908),  and,  of 
course,  we  have  no  very  definite  results.  All  of  the  children  without  exception 
improved  in  health,  and  gained  in  strength,  and  also  showed  good  mental  prog- 
ress. The  cost  of  the  school  per  capita  is  only  about  50  per  cent  more  than  in 
the  ordinary  schools,  and  we  believe  that  the  expense  is  fully  justified.  If  we 
had  a  large  enough  school,  so  that  it  could  be  graded,  the  cost  of  education 
would,  owing  to  saving  in  fuel,  probably  be  less  than  in  an  ordinary  school. 

Several  States  are  making  progress  in  these  directions. 

Connecticut,  Massachusetts,  and  Vermont  have  passed  laws  making  examina- 
tion of  eyes,  ears,  and  method  of  breathing  of  the  public  scholars  compulsory, 
while  New  York,  Illinois,  and  some  other  States  of  the  Middle  West  depend 
upon  the  voluntary  cooperation  of  the  teachers  in  making  this  examination. 
It  would  seem,  however,  that  whether  it  remains  voluntary  or  becomes  com- 
pulsory, its  success  will  be  greatly  enhanced  if  women  who  are  conducting 
teachers'  institutions  in  the  department  of  education  devote  a  half  hour  or  an 
hour  to  the  exposition  of  the  necessity  of  such  an  examination  and  also  in 
explaining  the  method  in  detail  and  the  method  of  tabulating  the  results,  so 
that  the  teachers  may  be  familiar  with  the  tests,  etc.,  when  they  have  to  make 
them.  With  the  great  power  lodged  in  the  department  of  education  in  this 
State,  it  would  seem  justifiable  to  make  this  compulsory.* 

We  in  this  country  should  profit  by  the  experience  of  older  coun- 
tries in  respect  to  school  hygiene.  Switzerland  has  led  the  nations 
in  its  concern  for  the  physical  welfare  of  its  children.  A  number  of 
other  European  countries  are  beginning  to  imitate  Switzerland  in 
attaching  supreme  importance  to  health  and  hygiene  in  educational 
work.  There  is  now  before  the  English  Parliament  a  bill  the  pur- 
pose of  which  is  to  establish  a  national  system  of  medical  inspection 
of  schools,  and  it  seems  probable  that  this  measure  will  be  enacted 
into  law. 

It  is  generally  recognized  by  physicians  and  educators  to-day  that 
many  children  in  the  schools  are  being  seriously  injured  through 
nervous  overstrain.''  Throughout  the  world  there  is  a  developing 
conviction  that  one  of  the  most  important  duties  of  society  is  to  de- 
termine how  education  may  be  carried  on  without  depriving  children 
of  their  health.  It  is  probable  that  we  are  not  requiring  too  much 
work  of  our  pupils,  but  they  are  not  accomplishing  their  tasks 
economically  in  respect  to  the  expenditure  of  nervous  energy.  Some 
experiments  made  at  home  and  abroad  seem  to  indicate  that  children 
could  accomplish  as  much  intellectually,  with  far  less  dissipation  of 
nervous  energy,  if  they  were  in  the  schoolroom  about  one-half  the 
time  which  they  now  spend  there.  German  educators  and  physicians 
are  convinced  that  a  fundamental  reform  in  this  respect  is  needed. 
In  fact,  among  school  children  we  are  learning  the  same  lesson  as 

o  A.  L.  Craig,  "  Report  of  the  standing  committee  on  contagious,  infectious,  and 
hereditary  diseases,"  Associated  Fraternities  of  America,  August  1,  1908. 

*  Twenty-eighth  Annual  Report  State  Board  of  Health  of  New  York,  1908. 

<'  See  Dr.  Adolph  Meyer,  "  What  do  Histories  of  Cases  of  Insanity  Teach  Us 
Concerning  Preventive  Mental  Hygiene  during  the  Years  of  School  Life?  "  The 
Psychologic  Clinic,  June  15,  1908. 


REPORT   ON    NATIONAL  VITALITY.  77 

among  factory  employees,  viz,  that  high  pressure  and  long  hours  are 
not  economy  but  waste  of  time. 

In  American  cities  one  of  the  greatest  needs  to-day,  in  order  to 
conserve  the  vitality  of  children,  is  the  establishment  of  playgrounds 
easily  accessible  to  all  the  children  of  any  community.  We  are  told 
that  the  physical  and  the  mental  are  inseparably  joined  together,  and 
if  the  one  is  defective  the  other  will  suffer  through  sympathy.  Now 
it  appears  to  be  impossible  to  develop  the  child  physically  in  any  way 
so  effectively  as  through  active  play.  Formal  gymnastics  can  accom- 
plish relatively  little.  The  child  must  have  some  end  to  attain  that 
arouses  its  enthusiasm,  and  that  demands  agility  and  strength  and 
endurance;  then  its  whole  bodily  mechanism  will  work  together  in 
harmony  to  achieve  this  end.  And  this  is  what  a  physical  training 
seeks  to  accomplish — to  make  the  body  a  fit  instrument  for  the  mind. 
Let  the  child  have  some  place  where  it  may  not  onlj''  play  games 
freely  without  fear  of  the  police  but  where  it  may  run  and  jump 
and  climb  and  swing  and  work  in  sand  and  throw  stones  and  wrestle, 
and  it  will  not  fail  to  make  the  most  out  of  the  body  nature  has  given 
it  as  a  housing  for  a  sound  and  efficient  mind. 

Even  if  playgrounds  were  of  no  value  in  social  development,  they 
would  still  be  of  inestimable  service  in  keeping  children  out  of  crime 
and  lessening  expense  for  police,  courts,  reformatories,  hospitals,  and 
prisons — a  point  which  was  strongly  emphasized  in  the  report  of 
1897  of  the  committee  on  small  parks  in  New  York.  If  a  boy's 
energies  are  not  used  up  in  wholesome  activity  they  will  surely  find 
expression  in  illegitimate  conduct.  The  boy  will  prey  upon  the  in- 
stitutions which  prevent  him  from  living  a  natural  life.  "  The  great- 
est enemy  to  the  police  is  the  boy,"  said  a  high  Philadelphia  official 
recently.  Go  to  the  storekeeper,  to  the  shopkeeper,  to  the  house- 
keeper, and  you  will  hear  the  same  story.  The  boys  steal,  break 
windows,  insult,  afflict,  upset  one  thing  and  another,  and  would  do 
almost  anything  they  hear  or  see  in  order  to  satisfy  that  burning 
instinct  for  play.  "  These  beginnings  of  vice  and  crime  were  the 
only  outlets  they  have  had  for  the  powers  with  which  nature  has 
endowed  them.  These  practices  were  their  only  or  chief  amusement, 
and  thus  happiness  to  them  became  synonymous  with  vice  and  fiendish 
delight  in  evil  doing."* 

But  in  studying  the  life  on  the  playgrounds  the  same  official  sees 
that  they  lay  the  foundations  for — 

strong,  manly,  bright,  and  happy  lives,  rescued  from  the  evil  habits  and 
tendencies  that  produce  misery  and  wretchedness.  *  *  *  Through  their  play 
In  this  manner  the  young  are  taught  how  to  live  together,  how  to  respect  each 
other's  rights,  how  to  be  kind,  gentle,  pure,  in  language  as  well  as  in  conduct. 
The  boy's  mouth  is  not  defiled  by  tobacco,  liquor,  or  profane  language.  The  dis- 
respectful and  vulgar  treatment  which  young  boys  and  girls  inflict  upon  each 
other  in  the  street  is  done  away  with.  The  playground  influences  are  brought 
into  the  home,  where  the  younger  brothers  and  sisters  treat  each  other  much 
differently  from  the  way  they  do  now ;  or,  to  put  it  the  other  way,  the  influ- 
ences of  the  home,  the  school,  and  of  the  church  are  thus  extended  outside  over 
the  whole  life  of  the  child.** 

To  playgrounds  may  be  joined  school  gardens,  which  Superin- 
tendent Maxwell  in  New  York  has  shown  would  not  be  expensive, 

"•  Secretary  of  Philadelphia  Culture  Extension  League. 


78  REPOKT   ON    NATIONAL  VITALITY. 

or  open-air  gymnasia,  or  any  other  equipment  tliat  will  give  children 
the  opportunity  to  develop  physically. 

Physical  education  is  a  part  of  the  training  in  many  public  schools 
and  in  a  still  greater  number  of  private  schools,  but  there  is  room 
for  improvement.  After  pointing  out,  in  a  recent  article  on  physical 
deterioration,  that  Germany,  France,  and  Austria  have  improved 
their  physical  development  by  compulsory  physical  training  in  all 
civil  and  military  educational  institutions,  the  Rev.  Percy  Stickney 
Grant  advocates  the  instalment  in  the  United  States  of : 

1.  An  effective  system  of  physical  education  as  a  recognized  part  of  all  public- 
school  systems.  By  "  effective "  I  mean  one  that  does  for  a  boy,  as  far  as 
his  physique  is  susceptible,  what  army  setting-up  exercises  do  for  a  recruit. 

2.  Athletic  exercises  in  schools,  using  gymnasia,  baths,  etc. 

3.  Open-air  exercises  and  sports  under  efficient  supervision. 

4.  Summer  camps  free  of  cost,  and  compulsory  attendance  for  boys  of  school 
age."^ 

The  study  of  hygiene  and  physiology  has  been  part  of  the  public 
school  curriculum  for  some  time,  but  has  been  regarded  by  physiolo- 
gists as  a  somewhat  partisan  and  unscientific  treatment  of  the  physi- 
ological effects  of  alcohol  and  tobacco.  It  should  be  recognized,  how- 
ever, that  it  has  had  a  salutary  effect  and  has  given  school  children  a 
better  idea  of  what  alcohol  means  than  the  most  of  them  had  before.* 
Local  topics  of  sanitation  may  well  be  taken  up,  as  in  New  Haven 
last  year  when  the  interest  of  all  the  city  school  children  was  enlisted 
in  behalf  of  a  "  clean  city."  Doctor  Stiles,  of  the  Public  Health  and 
Marine-Hospital  Service,  has  proposed  an  annual  "  health  week  "  in 
the  public  schools,  and  this  proposal  has  found  favor  in  several  States. 
In  Georgia  Chancellor  Barrow  has  proposed  an  annual  "  health  day  " 
in  the  public  schools  of  that  State,  which  would  be  devoted  to  lectures 
on  sanitation,  on  the  dangers  to  be  expected  from  unscreened  win- 
dows, and  on  the  character  of  the  hook-worm  disease,  with  suggestions 
as  to  its  elimination. 

At  present  the  schools  look  to  parents  to  instruct  their  children  in  the  sup- 
posedly simple  matters  of  regulating  eating  and  drinking,  exercise,  habits  of 
work,  and  sexual  habits,  while  the  parents  vaguely  hope  (if  they  think  about 
such  matters)  to  be  relieved  of  these  embarrassing  duties  through  the  schools. 
The  truth  is  that  neither  parents  nor  schools  are  to-day  able  to  give  this  much- 
needed  sort  of  education.  The  remedy  must  be  provided  by  the  schools,  which 
in  their  eagerness  to  impart  conventionalized  facts  are  now  quite  blind  to  some 
of  the  most  pressing  needs  of  their  pupils.  Through  the  schools  and  universi- 
ties (or  other  appropriate  organizations)  the  parents  of  the  future  must  be  edu- 
cated both  as  to  the  facts  and  the  moral  aspects  of  bodily  hygiene.  And  it  seems 
not  unreasonable  to  hope  that  some  of  the  lessons  now  learned  only  by  bitter 
experience,  after  much  that  is  best  in  life  has  been  sacrificed  to  ignorance  and 
uncurbed  impulse,  will  be  assimilated  sufficiently  early  in  life  to  mitigate  mate- 
rially the  lot  of  a  not  inconsiderable  part  of  mankind.  I  believe  the  lengthening 
of  the  span  of  hnman  life  to  be  among  the  attainable  results  of  such  teaching. 
Is  it  not  likely  that  as  men  grow  wiser  an  increasing  number  will  deliberately 
strive  so  to  regulate  their  lives  as  to  improve  the  expectation  of  crowning 
well-spent  days  with  the  peculiarly  fine  satisfaction  .of  old  age?'' 

If  the  school  building  were  a  model  of  ventilation,  lighting,  and 
sanitation,  it  would  not  only  conserve  the  health  of  the  school  chil- 

<^  Rev.  P.  S.  Grant,  North  American  Review,  February  1,  1907. 

*  See  Dr.  Helen  Putnam,  "  Studies  of  the  Present  Teaching  of  Hygiene, 
Through  Domestic  Science  and  through  Nature  Study,"  American  Academy 
Medicine  (Easton,  Pa.),  1905. 

'^  C.  A.  Herter,  M.  D.,  "  The  Common  Bacterial  Infections  of  the  Digestive 
Tract,"  New  York  (Macmillan),  1907,  p.  351. 


REPORT   ON    NATIONAL  VITALITY.  'J 9 

dren,  but  also  serve  as  an  object  lesson  for  hygienic  instruction.  In 
the  same  way  cooking  and  domestic  science  classes  could  be  made  to 
serve  the  double  purpose  of  providing  a  hygienic  noon  meal  and 
training  the  school  children,  especially  the  older  girls,  in  the  princi- 
pies  and  practice  of  this  vitally  important  subject.  Our  schools  are 
suffering  from  the  conventional  idea  that  education  comes  from 
books.  Education  is  preparation  for  life,  and  should  make  use  of 
every  efficient  method  and  element,  manual  training,  athletics,  ob- 
servational nature  study,  laboratory  experiments,  and  object  lessons 
of  all  sorts,  as  well  as  book  instruction. 

Section  5. — Voluntary  and  'business  organizations. 

A  host  of  distinctly  voluntary  associations  are  working  for  the 
improvement  of  hj^gienic  conditions.  Among  them  may  be  men- 
tioned the  National  Association  for  the  Study  and  Prevention  of 
Tuberculosis,  the  Society  for  Sanitary  and  Moral  Prophylaxis,  the 
Chicago  Society  of  Social  Ilygiene,  the  Connecticut  Society  of  Men- 
tal  Hygiene,  the  national  and  state  child  labor  committees,  the  Con- 
gress on  School  Hygiene,  the  Children's  Aid  societies,  the  Sunshine 
societies,  the  American  Playground  Association,  the  Visiting  Nurses' 
Association,  the  Red  Cross  Society,  the  American  Association  for 
Labor  Legislation,  the  numerous  temperance  organizations,  univer- 
sity settlements,  institutional  churches.  Young  Men's  Christian  Asso- 
ciation and  kindred  associations,  the  American  Physical  Education 
Society,  the  Boston  Health  Education  League,  and  the  American 
Health  League  established  by  the  Committee  of  One  Hundred  on. 
National  Health. 

That  various  large  bodies  of  men  are  waking  to  the  importance 
of  health  study  is  shown  by  the  appointment,  at  the  last  annual 
meeting  of  the  Associated  Fraternities  of  America,  of  a  committee 
on  infectious,  contagious,  and  hereditary  diseases,  with  Doctor  Craig, 
of  Chicago,  as  chairman.  Labor  unions  may  well  follow  this  exam- 
ple and  provide  for  the  education  of  their  members  in  the  subject 
of  hygiene.  This  could  be  effectively  combined  with  their  endeavors 
to  shorten  the  hours  of  labor.  Especially  unhygienic  is  the  arrange- 
ment by  which  a  man  has  no  interest  in  his  work  beyond  that 
represented  by  his  pay  envelope.  This  fact  has  been  recognized  by 
some  farsighted  employers  of  labor,  with  the  result  that  they  now 
employ  social  secretaries  or  "  welfare  workers  "  to  look  after  the 
general  well-being  of  employees.  A  social  secretary  watches  over 
the  health,  comfort,  and  happiness  of  the  force  during  working  hours, 
establishes  lunch  rooms,  rest  rooms,  mutual  aid  associations,  thrift 
funds,  and  penny  provident  banks.  Employers,  as  a  rule,  become 
eager  for  practical  suggestions  and  expert  advice  on  the  well-being 
of  their  employees  as  soon  as  the  matter  is  called  to  their  attention. 
Doctor  Favill,  president  of  the  Chicago  Tuberculosis  Institute,  after 
speaking  before  the  Commercial  Club,  was  urged  by  15  or  20  of  the 
large  employers  present  to  undertake  investigation  of  their  estab- 
lishments and  to  make  recommendations. 

Dr.  Hubert  Higgins  describes  an  interesting  experiment  carried 
out  in  a  mill  near  Paris,  where  there  were  employed  44  men  and  75 
women  and  children.  A  medical  officer  was  employed  to  supervise 
the  sanitary  appliances  and  regulations  and  to  give  careful  instruc- 


"SO  EEPORT   ON    NATIONAL  VITALITY. 

tion  and  explanations.  He  held  practical  instruction  classes  with 
the  mothers,  lecturing  on  diet  and  cooking,  cleanliness,  the  way  to 
take  body  temperatures,  and  how  to  look  at  the  children's  throats. 

This  experiment  was  entirely  successful,  though  the  doctor  lived  in  Paris. 
There  was  not  a  single  death  in  three  years.  There  were  one  or  two  cases  of 
scarlet  fever  and  diphtheria,  that  were  promptly  and  effectively  isolated.  This 
experiment  was  not  philanthropic,  but  financial,  the  employer  realizing  that 
he  had  better  value  in  work  from  healthy  hands.*^ 

A  few  factories  now  use  or  permit  the  use  of  a  reader  to  read  to 
their  employees,  where  the  manual  nature  of  their  work  is  such  as 
not  to  be  hindered  by  listening  to  a  story.  Others  use  a  piano  and 
have  their  employees  march  in  and  out  to  music.  The  curious 
physiological  relations  between  rhythm  and  work  are  now  being 
observed  by  physiologists.  Laboratory  tests  with  ergometers  seem 
to  show  that  more  work  can  be  done  under  the  stimulus  of  rhythm. 
Soldiers  and  sailors  have  for  ages  made  use  of  music  and  rhythm,  and 
it  would  not  be  beyond  the  range  of  possibility  if  the  factory  system 
-should  in  some  cases  find  more  use  for  it  than  at  present.^ 

Unconsciously,  business  corporations  have  also  made  changes  which 
tend  to  improve  the  sanitary  conditions  under  which  their  employees 
"work.  In  a  large  telephone  exchange  in  Chicago  the  perfect  working 
-of  the  apparatus  was  much  hampered  by  dust,  so  that  insulation  was 
seriously  affected.  To  obviate  this  condition  an  expensive  system 
was  put  into  operation,  by  which  the  air  was  washed  and  pumped 
into  the  rooms  under  ideal  conditions.  What  the  company  aimed  at 
was  the  perfect  health  of  its  apparatus,  but  it  gained  in  addition  a 
decided  improvement  in  the  health  of  its  employees." 

Another  similar  organization,  the  New  England  Telephone  and 
Telegraph  Company,  at  Cambridge,  Mass.,  ventilated  its  officer 
during  the  winter  of  1907-8  with  unusual  care,  with  the  result  that 
the  number  of  days  of  work  lost  by  its  60  female  employees  was  cut  in 
half. 

The  need  of  industrial  efficiency  is  driving  business  men  to  de- 
mand temperance  or  even  total  abstinance  among  their  employees. 
This  is  one  of  the  most  powerful  motives  to-day  working  against  the 
abuse  of  alcohol.  In  the  South  employers  and  the  public  see  that 
negroes  who  drink  are  inefficient  and  dangerous.  Railway  officers 
and  the  traveling  public  realize  that  public  safety  requires  sober 
locomotive  engineers  and  firemen.  Even  drinking  among  sailors  is 
being  discountenanced.  Doctor  Grenfell,  the  missionary  among  the 
Labrador  fishermen,  says :  "  Why  don't  I  want  to  see  liquor  used  at 
sea?  Because  when  I  go  down  for  a  watch  below,  I  want  to  feel 
that  the  man  at  the  wheel  sees  onlj?^  one  light  when  there  is  only  one 
light  to  see." 

Among  semipublic  institutions  with  power  to  exercise  prodigious 
influence  in  improving  the  public  health  are  the  life  insurance  com- 
panies. Just  as  fire  insurance  companies  make  efforts  to  decrease 
the  risk  of  fire,  so  life  insurance  companies  might  well  join  in  public 
health  movements  to  effect  a  reduction  in  the  human  death  rate. 

While  the  financial  motive  is  sordid,  it  should  be  utilized  because 
-of  its  tremendous  power.    The  insurance  companies  to-day  represent 

a  Hubert  Higgins,  "  Humaniculture,"  New  York   (Stokes),  1906,  pp.  209-211. 
*  See  Karl  Biicher,  "Arbeit  and  Rythmus,"  Leipzig,  1902. 
«  See  Outlook,  May  26,  1906. 


REPORT   ON   NATIONAL  VITALITY.  81 

an  invested  capital  of  over  $3,000,000,000.  An  actuary  recently  re- 
marked to  me,  in  connection  with  this  subject,  that  they  could  without 
feeling  it  contribute  great  sums  annually  to  the  preservation  of  public 
health.  Wlien  insurance  companies  w-ere  established,  the  old  dictum 
that  human  vitality  followed  a  fixed  law  served  probably  to  exclude 
the  idea  of  preventing  death  claims  rather  than  paying  for  them. 
Now  that  we  are  learning  the  preventabilit}^  of  disease,  the  time  must 
come  when  insurance  companies  will  take  an  active  part  in  the  fight. 
Even  a  single  company  would  probably  make  a  good  investment  if 
it  sought  to  educate  its  own  "  risks."  But  a  far  more  effective  method 
would  be  a  combination  of  all  companies  to  improve  public  health 
through  the  enactment  of  public  legislation — by  Congress,  state  legis- 
latures, municipal  governments,  and  in  numberless  other  ways.<^ 

Among  some  official  agencies  meant  to  promote  the  social  welfare 
are  two  recent  commissions  appointed  by  the  President — the  Homes 
Commission,  of  1907,  appointed  for  the  purpose  of  studying  the  hous- 
ing conditions  in  the  District  of  Columbia,  and  the  Commission  on 
Country  Life,  appointed  to  study  the  daily  life  of  the  farmer.  Farm 
sanitation  will  be  especially  considered. 

Finally,  there  is  a  public  yet  voluntary  agent  in  the  progress  of 
hygiene  that  must  not  be  overlooked,  namel}^,  the  modern  periodical. 
Not  only  do  the  daily  papers  devote  much  attention  to  questions  of 
health  and  hygienic  reform,  but  the  popular  magazines  have  taken  up 
the  fight  against  disease,  and  are  educating  the  popular  mind,  more 
surely  than  is  realized,  concerning  the  natural  and  normal  way  of  life. 
It  is  necessary  to  add,  however,  that  these  same  periodicals  often 
nullify  the  benefits  derivable  from  their  reading  matter  by  printing 
the  most  harmful  of  patent  medicine,  quack,  drug,  and  alcoholic  ad- 
vertisements. Public  odium  should  attach  to  newspapers  and  maga- 
zines that  advertise  hurtful  nostrums.  It  is  impossible  to  estimate 
the  harm  wrought  to  the  public  health  each  year  through  such  ad- 
vertising.^ 

The  daily  papers  are  especially  culpable  in  this  regard,  but  weeklies 
and  monthlies  are  not  wholly  clear  of  the  tain-t.  When  a  newspaper's 
advertising  space  is  once  bought  by  quacks  or  nostrum  sellers,  its  news 
columns  become  closed  at  once  to  matter  considered  objectionable  by 
such  advertisers.  Frequently  news  items  reflecting  directly  or  indi- 
rectly on  quackery  are  suppressed.  Notable  examples  of  publications 
that  have  taken  strong  ground  against  such  advertising  are  Collier's 
Weekly,  The  Outlook,  The  Ladies'  Home  Journal,  and  a  few — a  very 
few — daily  papers. 

«  Since  the  above  was  written  the  Committee  of  One  Hundred  on  National 
Health  has  urged  this  matter  before  the  Association  of  Life  Insurance  Presi- 
dents, which  body  has  appointed  a  committee  to  draw  up  plans.  Also  the  Metro- 
politan Life  Insurance  Company  hds  organized  a  bureau  of  cooperation  and 
information  to  aid  in  distributing  information  to  policy  holders  of  the  "  indus- 
trial" class. 

^  For  further  discussion  of  this  topic  see  a  pamphlet  by  Samuel  H.  Adams  on 
"  The  Great  American  Fraud,"  reprinted  by  the  American  Medical  Association 
from  a  series  originally  appearing  in  Collier's  Weekly,  and  "A  Century's  Crim- 
inal Alliance  between  Quacks  and  Some  Newspapers,"  by  Champe  S.  Andrews, 
Publications  of  the  Committee  of  One  Hundred,  1907. 


82  EEPORT   ON    NATIONAL  VITALITY. 

Chapter  IX. — Conservation  through  personal  hygiene. 

Section  1. — Its  importance. 

Following  public  and  semipublic  hygiene,  we  arrive  at  what  is  in 
many  respects  the  most  important  subject  of  all,  personal  hygiene.  It 
is  quite  true  that  the  individual  is  often  at  the  mercy  of  unclean 
streets,  bad  drainage,  impure  water  and  food,  and  other  shortcomings 
of  public  and  semipublic  hygiene.  On  the  other  hand,  his  own  per- 
sonal interest  is  necessary  in  order  to  form  the  public  opinion  which 
alone  can  result  in  effective  public  and  semipublic  hygiene,  while  that 
interest  is  still  more  necessary  to  make  such  hygiene  apply  directly  to 
his  own  person.  Clean  streets  are  of  use  only  as  they  make  the  air 
breathed  purer,  but  they  are  of  little  avail  to  the  household  which  does 
not  ventilate  its  rooms  or  which  keeps  them  in  a  state  of  filth.  The 
milk  supply  of  a  city  may  be  ideal,  but  all  the  pains  to  make  it  so 
will  be  set  at  naught  if  the  individual  consumer  allows  the  milk  to  be 
contaminated  after  it  is  delivered.  The  labeling  of  foods  and  drugs 
will  not  prevent  self-poisoning  through  alcohol,  nor  will  the  elimina- 
tion of  preservatives  from  foodstuffs  and  the  enforcement  of  sanita- 
tion in  their  manufacture  be  of  avail  if  in  their  preparation  for  the 
table  they  are  subjected  to  disease  and  dirt.  Thus  at  every  point  of 
hygienic  progress,  there  must  be  individual  cooperation  with  public 
efforts. 

When,  contrariwise,  health  organizations  and  officials  are  inefficient, 
the  individual  may,  in  spite  of  these  difficulties,  often  maintain  good 
health.  In  New  York  a  woman  who  was  the  occupant  of  a  tenement 
overcame  tuberculosis  by  sitting  daily  on  her  fire  escape.  The  air 
was  not  the  best,  but  it  was  much  better  than  indoors.  Similar  results 
have  been  obtained  by  workmen  in  Brockton  shoe  factories,  who,  in 
spite  of  insanitary  working  places,  and  without  cessation  of  work, 
conquered  tuberculosis  by  sleeping  on  the  roofs  of  their  houses  at 
night. 

Observation  shows  that  many,  possibly  most,  of  the  world's  most 
vital  men  and  women  have  virtually  made  over  their  constitutions 
from  weakness  to  strength.  Cornaro,  the  famous  nonogenarian,  Kant, 
and  Humboldt  are  cases  typical  in  different  fields  of  achievement. 
Cornaro,  a  Venetian  nobleman  born  about  the  middle  of  the  fifteenth 
century  and  given  up  to  die  at  the  age  of  37,  forswore  all  unhygienic 
habits  and  began  to  live  "  the  temperate  life,"  his  abstemiousness 
applying  especially  to  food.  His  age  at  death  is  variously  estimated, 
but  he  lived  to  be  at  least  97.  When  over  90  he  wrote  a  treatise  on  lon- 
gevity, laying  down  as  the  chief  rules  of  a  normal  life,  care  in  eating 
and  drinking,  and  the  avoidance  of  melancholy  and  passion." 

Centenarians  have  usually  been  persistent  followers  of  some  rule  or 
rules  of  rational  hygiene,  even  though  unconsciously.^ 

Metchnikoff  points  out''  that  part  of  the  supposed  inheritance  of 
longevity  may  not  be  inheritance,  but  similarity  of  environment,  and 
that  it  very  frequently  happens  that  husband  and  wife  both  live  to  be 

"See  L.  Cornaro,  "The  Art  of  Living  Long"  (English  translation,  Wm.  F. 
Butler,  Milwaukee),  1903. 

^  Metchnikoff,  "The  Prolongation  of  Life,"  p.  141. 
c  Ibid.,  p.  86. 


REPORT   ON   NATIONAL,  VITALITY.  83 

over  100.  This  could  scarcely  happen  by  accident,  but  must  be  due  to 
similar  habits  or  environment. 

Humboldt  confessed  to  a  fellow-student  that  in  the  first  years  of 
his  childhood  his  tutors  were  doubtful  whether  even  ordinary  powers 
of  intelligence  would  ever  be  developed  in  him,  and  that  it  was  only 
in  the  advanced  part  of  his  boyhood  that  he  began  to  show  any  evi- 
dence of  mental  vigor.  As  a  boy  he  suffered  from  debility  which  not 
infrequently  produced  great  prostration.'^ 

Of  recent  examples  may  be  mentioned  a  young  physician  who  was 
given  up  to  die  of  tuberculosis  five  years  ago,  but  who  to-day  can 
run  25  miles  without  a  rest ;  and  Horace  Fletcher,  who  in  his  46th  year 
was  rejected  for  life  insurance,  but  who  later  not  only  obtained  his 
insurance,  but  proved  his  powers  of  endurance  by  cycling  190  miles 
on  his  50th  birthday. 

And  not  only  can  weakness,  if  recognized  early  enough,  be  turned 
into  strength,  but  strength,  however  great,  may  be  dissipated  in  an 
incredibly  short  time. 

Personal  hygiene  means  the  strengthening  of  our  defenses  against 
disease.  Public  hygiene  seeks  to  destroy  the  germs  before  they  reach 
our  bodily  defenses.  These  two  branches  of  hygiene  are  simply  the 
two  forms  of  warfare,  defensive  and  offensive.  Both  are  of  tran- 
scendent importance,  but  the  defensive  warfare  is  more  within  our 
power.  We  always  have  our  defending  garrison,  the  white  blood 
corpuscles,  to  deliver  us  from  our  enemies.^ 

Section  2. — Branches  of  personal  hygiene. 

Personal  hygiene  comprises  hygiene  of  environment  (air,  soil, 
dwelling,  clothing)  ;  hygiene  of  nutrition ;  and  hygiene  of  activity. 

Man  is  more  dependent  upon  the  atmosphere  than  ujjon  any  other 
environmental  factor.  His  body  is  bathed  in  air  and  his  most  vital 
function,  respiration,  depends  upon  it.  Deprived  of  air,  he  will 
shortly  suffocate.  If  the  air  is  confined  and  impure,  his  health  will 
be  affected.  Ideal  air  should  first  of  all  be  pure — i.  e.,  free  from  in- 
jurious bacteria,  from  dust,  smoke,  and  noxious  gases.  It  should 
also  conform  to  certain  standard  conditions  of  humidity  and  tem- 
perature. In  this  field  lie  the  sciences  of  climatology  and  mjcteor- 
ology.  Man  learned  long  ago  how  to  make  himself  almost  inde- 
pendent of  climatic  and  atmospheric  conditions  by  the  use  of  dwell- 
ings and  clothing.  These  contrivances,  however,  while  protecting 
him  from  the  elements,  have  brought  evils  of  their  own.  The  great 
scourge  of  tuberculosis,  for  instance,  is  principally  an  indoor  disease. 

Intimately  related  to  the  appropriation,  through  the  lungs,  of  oxy- 
gen from  the  atmosphere  is  the  ingestion  of  food  and  drink  through 
the  alimentary  canal.  Normal  health  conditions  demand  in  the  case 
of  ingested  materials,  as  in  the  case  of  respired  air,  the  greatest  possi- 
ble purity,  freedom  from  injurious  bacteria,  and  the  absence  of  sub- 
stances hurtful  mechanically  or  chemically. 

Finally,  the  ideal  conditions  of  health  require  perfect  balance  of 
work,  plaj^,  and  sleep. 

"■ "  Life  of  Alexander  von  Humboldt,"  by  Lowenberg  Ave-Lallewort  and  Dore, 
translated  by  Jane  and  Caroline  Lassell,  New  York  (Lee  &  Sliepard),  1873, 
Vol.  I,  pp.  30-32. 

*  Metchnikoff,  "  The  New  Hygiene,"  p.  14. 


84  REPORT   ON   NATIONAL  VITALITY. 

While  absolutely  perfect  conditions  in  these  three  branches  of  hy- 
giene are  unobtainable,  hygienic  progress  consists  in  approaching 
these  ideals  as  closely  as  possible. 

The  rules  of  personal  hygiene  are  expressed  in  standard  medical 
works  on  the  subject.  There  is  nothing  novel  in  the  brief  resume 
which  follows.  The  radical  changes  in  habits  of  living  which  are 
now  being  advocated  and  to  some  extent  practiced  imply  nothing^ 
new.  They  have,  for  the  most  part,  long  been  commonplaces  of  the 
medical  profession.  The  knowledge  is  old.  It  is  the  application 
which  is  new.  Medical  men  have  long  been  telling  their  patients  to 
get  plenty  of  fresh  air  and  to  masticate  their  food.  But  until  re- 
cently their  advice  has  fallen  on  deaf  ears. 

Section  3. — TJie  hygiene  of  environment. 

Air  hygiene  deals  first  of  all  with  ventilation."  The  importance  of 
properly  ventilating  houses  is  so  great  that  to  secure  this  end  the  ar- 
chitecture of  houses  will  have  to  be  changed.  The  worst  historical 
instances  of  bad  ventilation  are  the  imprisonment  and  virtual  suffoca- 
tion of  146  persons  in  the  "  Black  Hole  "  of  Calcutta  and  the  confine- 
ment of  300  men  in  an  underground  room  after  the  battle  of  Auster- 
litz.  The  evils  of  overcrowding  come  mainly  from  exhaled  air  and 
from  the  effluvia  thrown  off  by  the  skin.  Not  only  does  overcrowding 
bring  bad  air,  but  it  also  increases  the  opportunity  for  infection. 

The  air  in  our  houses  has  impurities  of  its  own.  Oil  and  gas  vitiate 
it.  Electric  lights  are  hygienic  in  this  respect.  Air  is  never  quite 
free  from  dust  impurities.  Aitkin  estimates  that  country  air  carries 
2,000  dust  particles  per  cubic  centimeter,  city  air  3,000,000,  and  in- 
habited rooms  30,000,000. 

In  a  clean  hospital  ward,  when  air  was  agitated  by  dry  sweeping, 
the  number  of  colonies  of  bacteria  collected  on  a  given  exposure  rose 
from  26  to  532,  showing  the  effect  of  ordinary  broom  sweeping.  The 
broom  is  now  being  replaced  by  the  carpet  sweeper,  and  the  carpet 
sweeper  in  turn  by  the  vacuum  cleaner.  Each  step  represents  progress 
in  the  elimination  of  dust.  The  removable  rug  is  in  this  regard  an 
improvement  over  the  carpet. 

Air  may  even  be  poisoned  by  the  chemicals  contained  in  wall  paper 
or  in  the  plaster  of  a  brick  and  mortar  dwelling. 

The  one  place  where  the  individual  has  more  control  over  the  air 
he  breathes  than  anywhere  else  is  his  sleeping  room.  He  may  be 
powerless  to  control  the  air  in  his  place  of  work,  or  even  in  the  rooms 
where  he  lives  during  the  day.  But,  except  where  he  shares  a  bed- 
room with  others  who  are  averse  to  modern  ideas  of  ventilation,  he 
can  largely  control  the  air  supply  during  sleep,  and  this  means  during 
one-third  of  his  whole  time.  He  can  open  wide  his  windows  and  in 
many  cases  arrange  actually  to  sleep  out  of  doors.  The  growing  prac- 
tice of  sleeping  out  of  doors  is  one  of  the  most  significant  signs  of  the 
times.  Only  those  who  have  tried  it  realize  the  benefits.  The  air 
supply  in  public  places  would  be  under  the  control  of  individuals,  if 
organized  in  protest ;  and  our  churches,  theaters,  public  halls,  railway 
coaches,  and  railway  sleepers  would  be  properly  ventilated  if  the 

''See  Richards  and  Woodman,  "Air,  Water,  and  Food,"  New  York  (Wiley), 
1904 ;  also  Carpenter,  "  Heating  and  Ventilating  Buildings,"  New  York  (Wiley), 
1905;   Sykes,  "  Public  Health  and  Housing  "  London  (King),  1901,  216  pp. 


KEPORT    ON    NATIONAL    VITALITY.  85 

public  demanded  improvement.  Such  a  "  score  card  "  as  Prof.  John 
K.  Commons  has  devised  for  measuring  the  relation  of  housing  con- 
ditions to  an  ideal  standard  might  well  be  used  in  measuring  the 
health  utility  of  public  places. 

The  windows  of  living  and  work  rooms  may  be  opened  in  summer 
and  somewhat  in  winter,  jjrovided  a  window  board  is  used,  to  deflect 
the  cold  air  ujDward  from  the  sill.  It  then  does  not  form  a  cold 
stratum  on  the  floor,  but  mixes  evenl}^  with  the  air  of  the  room.  This 
simple  device  would  go  far  to  solve  the  question  of  winter  shut-ins 
and  their  ailments.  In  many  cities  sleeping  balconies  are  not  uncom- 
mon among  the  dwelling  houses. 

The  many  benefits  from  a  pure  air  supply  are  only  beginning  to  be 
realized.  For  instance,  as  long  as  "  the  outdoor  life  "  is  lived  a  cold 
is  almost  impossible.  Army  officers  have  noted  that  as  long  as  the 
men  are  on  the  march  and  sleep  outdoors  they  hardly  ever  have  colds, 
but  that  they  become  troubled  with  these  as  soon  as  they  get  indoors. 
Franklin,  a  century  ago,  knew  these  facts,  though  few  of  the  present 
generation  are  acquainted  with  them.  He  believed  "  that  people  who 
live  in  the  forest,  in  open  barns,  or  with  open  windows,  do  not  catch 
cold,  and  that  the  disease  called  '  a  cold  '  is  generally  caused  by  impure 
air,  lack  of  exercise,  or  from  overeating."  He  came  to  the  conclusion 
that  influenzas  and  colds  are  contagious — a  doctrine  which,  a  century 
and  a  half  later,  was  proved,  through  the  advance  of  bacteriological 
science,  to  be  sound.  The  following  sentence  exhibits  remarkable  in- 
sight, considering  the  state  of  medical  art  at  that  time :  "  I  have  long 
been  satisfied  from  observation  that  besides  the  general  colds  now 
termed  '  influenzas  '  (which  may  possibl}^  spread  by  contagion,  as  well 
as  by  a  particular  quality  of  the  air),  people  often  catch  cold  from 
one  another  when  shut  up  together  in  close  rooms  and  coaches,  and 
when  sitting  near  and  conversing  so  as  to  breathe  in  each  other's 
transpiration ;  the  disorder  being  in  a  certain  state."  In  the  light  of 
present  knowledge  what  a  cautious  and  exact  statement  is  that.*^ 

Jolin  Muir,  the  geologist  and  naturalist,  says  that  he  finds  home 
the  most  dangerous  place  he  can  visit. 

As  long  as  I  camp  out  in  tlie  mountains  without  tents  or  blankets  I  get  along 
very  well,  but  the  minute  I  get  into  a  house  and  have  a  warm  bed  and  begin  to 
live  on  fine  food,  I  get  into  a  draft,  and  the  first  thing  I  know  I  am  coughing 
and  sneezing  and  threatened  with  pneumonia,  and  am  altogether  miserable. 

Atmospheric  evils  come  from  improper  ventilation,  and  affect  either 
the  respiratory  organs  of  the  body  or  the  skin.  It  has  been  supposed 
until  recently  that  the  presence  of  carbon  dioxid  gas  in  vitiated  air 
was  the  chief  evil  caused  by  such  air.  Impure  air  will  affect  the 
lungs  harmfully,  but  not  till  the  amount  of  carbon  dioxid  con- 
tained is  very  large.  Guinea  pigs,  on  which  the  effects  of  bad  air 
were  observed,  were  not  seriously  affected  by  the  carbon  dioxid  till 
it  amounted  to  14  per  cent  of  the  volume  of  the  air.  Fliigge  and 
others  have  found  that  the  evil  of  close  atmospheres  is  largely  a  result 
of  elevated  temperature,  humidity,  and  absence  of  air  currents.  Tests 
were  made  on  men  who  sat  in  impure  air,  but  breathed  pure  air 
through  tubes,  and  thej  presented  all  the  symptoms  usually  resulting 
from  bad  ventilation, 

"  From  "  Benjamin  Franklin  as  Printer  and  Philosopher,"  address  of  Presi- 
dent Charles  W.  Eliot  before  American  Philosophical  Association,  April  20,  1906>. 


86  REPOET   ON   NATIONAL  VITALITY. 

Air  baths  have  been  shown  to  be  as  important  for  bodily  health  as 
water  baths.  For  this  purpose  porous  clothing  should  be  worn  and 
no  more  of  it  than  is  needful.  Impervious  cloth  and  rubber  are  prob- 
ably injurious  as  clothing.  Loosely  woven  worsteds,  or  linen  and 
cotton  mesh  are  best  adapted  to  let  the  air  play  on  the  skin.  Clothing, 
to  be  hygienic,  should  not  constrict  the  body.  Tight  shoes,  and 
especially  tight  corsets,  are  distinctly  injurious,  and  the  injury  to 
mothers  from  the  latter  may  be  felt  by  the  next  generation.  Another 
insanitary  feature  in  clothes  is  the  trailing  skirt,  which  drags  indoors 
the  sputum  of  consumptives  and  germ-laden  dirt  from  the  sidewalk. 

Closely  connected  with  air  and  ventilation  is  light.  The  benefit  of 
sunshine  in  killing  germs  and  improving  bodily  vigor  in  every  way 
is  too  well  known  to  need  more  than  mention.  Tuberculosis  and  other 
germs  thrive  only  in  dark,  damp,  ill-ventilated  places. 

Light  has  its  most  important  bearing  on  the  human  health  through 
the  sense  of  sight.  Its  relation  to  eye  strain  has  been  discussed  else- 
where. Headaches,  backaches,  indigestion,  hysteria,  and  epilepsy  are 
often  aided  by  glasses. 

Section  4. — The  hygiene  of  nutrition. 

A  primary  necessity  for  hygienic  living  is  good  drinking  water. 
The  modern  man  of  means  insists  upon  good  water,  and,  as  a  result, 
the  traveling  public  is  now  able  to  get  first-class  water  in  cars,  hotels, 
and  other  public  places.  The  improvement  was  brought  about  by 
the  appreciation  by  the  consumer  of  the  danger  of  drinking  impure 
water.  It  is  the  consumer  who  has  it  in  his  power  to  bring  about  the 
necessary  reforms  in  public  hygiene.  When  he  really  values  hygienic 
environment  producers  will  supply  it.  Professor  Sumner  has  told  us 
that  persons  in  the  middle  ages  sometimes  drank  out  of  their  castle 
moats,  which  contained  sewage.  Even  in  New  York  to-day  the  roof 
tanks  are  sometimes  used  as  baths  or  laundries;  and  they  accumu- 
late dust  and  flies  very  rapidly.  Only  a  few  years  ago  the  aldermen 
in  a  prominent  western  town  laughed  out  of  court  a  physician  who 
called  their  attention  to  dangers  which  were  real,  but  which  they  be- 
lieved imaginary^  from  a  polluted  water  supply. 

The  scientific  study  of  diet  has  only  just  begun  and  few  authori- 
tative results  can  yet  be  stated.  To  avoid  a  lengthy  review  of 
controversial  literature  it  seems  best  to  pass  the  subject  over  rapidly, 
referring  the  reader  for  further  information  to  some  of  the  principal 
books  on  the  subject. 

We  have  already  seen  the  surprising  improvement  in  endurance 
which  followed  the  adoption  of  thorough  mastication  in  place  of  the 
ordinary  food  bolting.  Mr.  Gladstone  used  to  be  noted  for  his  care 
in  slowly  masticating  his  food,  and  latterly  Mr.  Horace  Fletcher  has 
aroused  the  interest  of  the  public  in  the  subject  in  Europe  and  Amer- 
ica.«  He  has  also  stimulated  a  large  number  of  physiologists  to  study 
the  subject  of  mastication,  the  protein  ration,  and  their  relation  to 
strength  and  endurance. 

"  See  Horace  Fletcher,  "  The  A,  B-Z  of  our  Own  Nutrition,"  New  York 
(Stokes),  1903;  Dr.  Hubert  Higgins,  "  Humaniculture,"  New  York  (Stokes), 
1906;  and  Irving  Fisher,  "The  Effect  of  Diet  on  Endurance,"  publications  of 
Yale  University,  Transactions  of  the  Connecticut  Academy  of  Arts  and  Sciences, 
1907. 


REPORT    ON    NATIONAL  VITALITY.  87 

A  great  deal  has 'been  written  as  to  what  foods  are  best.  There 
exist  various  dietetic  cults,  such  as  vegetarians  and  fruitarians,  raw- 
food  advocates,  etc.  The  question  of  what  foods  are  ideally  best  is 
too  large  a  one  to  be  entered  upon  here.  The  evidence  seems  to  point 
to  a  general  conclusion  that  no  hard-and-fast  rule  of  exclusion  is 
advisable,  and  that  the  value  of  different  foods  varies  with  the  indi- 
vidual and  with  his  activity,  locality,  physical  condition,  etc.  His 
own  instinct,  restored  and  educated  by  avoiding  the  pernicious  habit 
of  food  bolting,  may  be  made  a  truer  guide  than  the  wisest  physician 
or  physiologist.  The  same  rule  applies  to  the  amount  of  food  to  be 
eaten,  as  well  as  to  the  proportions  of  protein,  fat,  carbohydrates,* 
and  mineral  salts.     Food  bolting  often  leads  to  overeating. 

It  should  be  noted  that  the  conclusions  of  Chittenden  and  others 
are  not  in  favor  of  a  vegetarian  regime,  but  of  a  low  protein  regime, 
whether  vegetarian,  lacto-vegetarian,  or  with  flesh  foods  in  modera- 
tion. The  main  point  is  moderation  of  the  foods  highest  in  protein, 
such  as  the  whites  of  eggs  and  meats  (especially  lean  meats). 

It  would  seem  that  the  safest  course  for  the  average  man  is  to  fol- 
low the  appetite,  simply  guiding  it  toward  a  low  protein  diet  by  thor- 
ough mastication,  and  by  giving  the  benefit  of  the  doubt  to  foods  low 
in  protein.  A  reduction  in  the  use  of  meat  will  increase,  and  probably 
cheapen,  our  national  food  suppl}^  The  raising  of  cattle  requires 
much  more  land  than  the  raising  of  cereals,  fruits,  nuts,  and  vege- 
tables yielding  the  same  amount  of  food  value.  As  this  will  be  a  most 
important  economic  problem  during  the  next  hundred  years,  the  ques- 
tion of  the  character  of  our  food  supply  should  be  most  carefully 
considered  in  the  study  of  the  conservation  of  natural  resources.  It 
is  interesting  to  note,  in  this  connection,  that  during  the  last  century 
the  consumption  of  flesh  foods  in  the  United  States  has  considerably 
decreased.^ 

The  subject  of  auto-intoxication  as  a  consequence  of  excessive  pro- 
tein has  already  been  mentioned.''  To  avoid  auto-intoxication  the 
putrefactive  bacteria  may  be  neutralized  by  lactic  bacilli,  such  as  are 
contained  in  sour  milk.  Another  preventive  is  regular  attention  to 
thorough  evacuation. 

Diseased  foods  are,  needless  to  say,  dangerous.  Oysters  are  often 
planted  in  waters  polluted  with  sewage,  with  the  result  that  epidemics 
of  typhoid  fever  have  been  traced  to  their  consumption. 

The  housewife  must  be  the  guardian  of  the  family  in  these  respects, 
and  in  the  cooking,  preparation,  and  arranging  of  food  generally. 
These  now  constitute  "  domestic  science,"  which  is  justly  winning 
recognition  as  one  of  the  most  potent  of  all  hygienic  agencies.    When 

«  For  a  short  method  of  measuring  these  magnitudes,  see  Irving  Fisher,  "A 
New  Method  of  Indicating  Food  Values,"  American  Journal  of  Physiology,  Vol. 
XV,  No.  V,  April  2,  1906;  and  for  its  practical  application  see  "A  Graphic 
Method  in  Practical  Dietetics,"  Journal  American  Medical  Association,  Vol. 
XLVIII,  April  20,  1907.  See  also,  "  Statistics  of  Diet  in  Consumptive  Sana- 
toria," American  Journal  Medical  Sciences,  September,  1906. 

^  See  G.  K.  Holmes,  "  Meat  Supply  and  Surplus,"  Bureau  of  Statistics,  De- 
partment of  Agriculture,  Bulletin  55,  1907,  p.  47.  Mr.  Holmes  finds  that  the 
consumption  of  dressed  meat  per  capita  in  the  United  States  decreased  between 
1840  and  1900,  40  per  cent,  and  between  1890  and  1900,  25  per  cent. 

<>  Supra,  Chap.  V.  See  also  Herter's  "  Common  Infection  of  the  Digestive 
Tract." 

84369— No.  30—09 7 


88  EEPOKT    ON    NATIONAL   VITALITY. 

the  kitchen  becomes  a  scientifically  conducted  laboratory  we  shall 
have  the  basis  of  a  sound  "  home  economics." 

Section  5. — Drug  haMts. 

It  would  scarcely  be  an  exaggeration  to  say  that  the  first  rule  of 
hygiene  is  to  avoid  poisons.  Poisons  may  be  generated  within  us 
or  ingested  from  without. 

Drug  habits  take  numerous  forms,  and  they  are  more  prevalent 
than  most  persons  realize.  The  commonest  form  of  intoxication  is 
alcoholic*  It  is  interesting  to  observe  the  change  which  has  come 
about  in  the  attitude  of  scientists  toward  alcohol.  From  having  en- 
joyed a  high  place  in  materia  medica,  it  is  in  danger  of  being  com- 
pletely discredited.^  So  far  as  its  habitual  use  is  concerned  the  only 
question  which  remains  in  debate  is  whether  in  minute  quantities  it 
may  be  innocuous  or  even  beneficial.  In  any  except  minute  quantities 
it  has  been  shown  to  be  injurious. 

It  lowers  the  resistance  of  the  white  corpuscles,  which  are  the  natural  de- 
fenders of  the  body.  Although  the  phagocytes  belong  to  the  most  resistant 
elements  of  our  body,  yet  it  is  not  safe  to  count  on  their  insensibility  toward 
poisons.  It  is  well  known  that  persons  who  indulge  too  freely  in  alcohol  show 
far  less  resistance  to  infectious  diseases  than  abstemious  individuals.'' 

Here  is  the  gravest  indictment  that  may  be  brought  against  the 
abuse  of  alcohol.  It  is  not,  however,  the  only  one.  The  relation  of 
drinking  to  insanity,^  peripheral  neuritis,  Bright's  disease,  cirrhosis 
of  the  liver,  inflammation  of  the  stomach,  arteriosclerosis  (a  most 
common  cause  of  apoplexy),^  tuberculosis;  f  to  crime  in  all  its  forms,^ 
and  to  all  the  possibilities  incident  to  the  hereditary  transmission  of 
a  weakened  organism ''  has  been  pointed  out.  If  personal  hygiene 
is  a  duty,  it  is  the  duty  of  every  man  to  recognize  the  danger  from 
alcohol  to  himself  and  to  his  progeny  yet  unborn.  Instead  of  copying 
the  habits  of  others,  he  may  consider  the  responsibility  of  causing 
others  to  copy  his. 

A  subcommittee  of  the  Committee  of  Fifty  for  the  investigation 
of  the  liquor  problem  published  in  1899  a  volume  jon  the  economic 

"■  For  a  discussion  of  the  physiological  effects  of  alcohol,  see  Physiological 
Aspects  of  the  liiquor  Problem,  investigations  made  under  the  direction  of 
W.  O.  Atwater,  John  S.  Billings,  H.  P.  Bowditch,  R.  H.  Chittenden,  and  W.  H. 
Welch,  subcommittee  of  the  Committee  of  Fifty ;  New  York,  Houghton  &  Mifflin, 
1903,  2  vols. ;  and  The  Liquor  Problem,  a  Summary  of  Investigations  Conducted 
by  the  Committee  of  Fifty,  1893-1903,  by  John  S.  Billings,  Charles  W.  Eliot, 
Henry  W.  Farnam,  Jacob  L.  Greene,  and  Francis  G.  Pea  body,  1905. 

^  The  role  of  alcohol  as  a  predisposing  cause  of  disease  has  already  been  noted. 
It  has  long  been  known  that  drunkards  have  a  very  slim  chance  of  recovery  when 
attacked  by  pneumonia,  and  it  is  noted  also  that  the  mortality  among  moderate 
drinkers  is  higher  than  among  total  abstainers.  This  fact  has  long  been 
known  to  life-insurance  companies  as  holding  good  for  many  diseases  other 
than  pneumonia.    Osier :  Modern  Medicine,  Vol.  II,  p.  628. 

'^  Metchnikoff :  The  New  Hygiene,  p.  25. 

^  See  "  Twenty-sixth  Annual  Report  of  Massachusetts  Bureau  of  Labor,"  1965. 

e  Ditman,  loc.  cit.,  p.  47. 

^  See  John  Huber,  M.  D.,  "  Predisposition  to  tuberculosis,"  The  Medical  News, 
December  26,  1903,  p.  12.    Also  reports  of  Phipps  Institute,  Philadelphia. 

0  See  Boies's  various  works,  the  "  Reports  of  the  Committee  of  Fifty,"  and  Re- 
port of  the  Massachusetts  Bureau  of  Labor  Statistics,  1895. 

''  See  Henry  Smith  Williams,  M.  D.,  "Alcohol  and  the  Individual,"  McClure'a 
Magazine,  October,  1908,  pp.  704-712. 


REPORT   ON    NATIONAL  VITALITY.  89 

aspects  of  the  problem.  The  investigation  covered  a  period  of  about 
three  years  and  was  carried  on  under  the  general  direction  of  Prof. 
Henry  W.  Farnam,  of  Yale  University.  The  general  conclusions  of 
this  investigation  were  that  of  the  poverty  which  came  under  the 
notice  of  the  charity  organization  societies  about  25  per  cent  could 
be  traced  directly  or  indirectl}''  to  the  use  of  liquor;  of  the  poverty 
found  in  almshouses,  about  37  per  cent.  In  the  investigation  of 
crime,  the  conclusion  was  reached  that  liquor  was  a  first  cause  in  31 
per  cent  of  the  criminals  studied,  and  that  it  entered  in  as  a  cause, 
directly  or  indirectly,  in  50  per  cent. 

The  investigation  made  by  the  Massachusetts  bureau  of  statistics  of 
labor  in  1895  indicated  the  following  percentages  due  to  alcoholism: 

Per  cent. 
Crime 84.41 

Pauperism , 48 

Insanity 35 

Several  English  life-insurance  companies — the  Sceptre,  the  United 
Kingdom,  and  General  Provident  and  others — have  found  by  their 
statistics,  running  over  forty  years,  that  abstainers  have  a  death  rate 
about  23  per  cent  lower  than  nonabstainers.®  Since  the  figures  of  the 
Mutual  Life  Insurance  Company  of  New  York  ^  give  the  same  advan- 
tage to  American  abstainers  (23  per  cent  lower  death  rate),  it  seems 
fair  to  take  the  available  computations  of  the  English  life  insurance 
companies  as  a  basis  for  estimating  the  saving  of  life  that  would 
result  in  the  United  States  if  individuals  should  decide  to  give  up  the 
use  of  alcohol.  It  should  be  remembered,  however,  that  the  favorable 
figure  of  total  abstainers  is  partly  due  to  the  fact  that  as  a  class 
they  practice  personal  hygiene  in  all  its  forms. 

A  basis  for  computing  the  sickness  that  might  be  saved  by  total 
abstinence  is  furnished  by  comparison  between  the  sick  rates  of 
abstaining  and  nonabstaining  societies,  made  by  Mr.  H.  Dillon 
Gouge,  public  actuary  of  South  Australia,  in  1892.  He  found  that 
the  average  weeks  of  sickness  in  three  societies  of  abstainers  was 
1.248 ;  in  three  societies  of  nonabstainers  the  average  weeks  of  sick- 
ness w^as  2.317  (lacking  only  one-sixth  of  being  twice  as  much). 

Absintlie  in  France  has  become  almost  as  clearly  a  cause  of  national 
degeneration  as  opium  in  China.  Fortunately  for  our  own  country 
there  exists  here  a  more  determined  effort  than  in  most,  if  not  all 
other  nations,  to  be  rid  of  alcoholism.  The  movement  has  been 
formidable  enough  to  arouse  anxiety  among  those  whose  capital  is 
invested  in  breweries,  distilleries,  and  saloons.  The  movement 
reaches  its  maximum  momentum  in  the  west  and  the  south  of  the 
United  States.  It  is  significant  of  the  rapid  change  of  sentiment  in 
regard  to  the  liquor  question  that  physiologists,  physicians,  educators, 
and  publicists  are  now  becoming  so  thoroughly  impressed  with  the 
importance  of  suppressing  the  evils  of  alcohol. 

The  younger  members  of  the  Kaiser's  family  in  Germany  are 
opposed  to  the  German  habits  in  regard  to  the  use  of  alcohol,  and  the 
son  of  the  Kaiser  chose  for  his  university  one  where  there  was  less 

« Letter  from  Miss  C.  F.  Stoddard,  secretary  of  the  Scientific  Temperance 
Federation. 

^  "  Effect  of  Total  Abstinence  on  the  Death  Rate,"  by  Joel  G.  Van  Cise,  actu- 
ary of  the  Equitable  Life  Assurance  Company  of  the  United  States. 


90  REPORT    ON    NATIONAL    VITALITY. 

drinking  than  at  other  universities.  President  Eliot,  of  Harvard 
University,  has  recently  taken  a  strong  position  against  the  use  of 
alcohol,  even  "  in  moderation." 

Another  common,  though  less  injurious,  source  of  self -poisoning 
is  tobacco,  which  is  known  to  stunt  the  growth  of  the  young,  to  lead 
to  sluggishness  and  weakened  hearts  ("  tobacco  hearts  "),and  to  cause 
dyspepsia  and  neurasthenia. 

Snuff  taking  has  almost  disappeared  as  a  habit  in  this  countr3^ 
Chewing  tobacco  is  still  common,  though  no  longer  defended  by 
hygienists.  "  Inhaling  "  is  more  common,  though  also  usually  con- 
demned on  grounds  of  health.  Smoking  shows  no  signs,  as  yet,  of 
decreasing.  In  moderation  it  may  not  be  injurious.  There  are  no 
definite  proofs  on  either  side.    But  smokers  are  seldom  moderate. 

Doctor  Seaver,  of  the  Yale  Gymnasium,  found  that  of  the  187  men 
in  the  class  of  1891,  Yale  College,  those  not  using  tobacco  during  the 
college  course  had  gained  over  the  users  of  tobacco  in  weight  32  per 
cent,  in  height  29  per  cent,  in  growth  of  chest  19  per  cent,'  and  in  lung 
capacity  66  per  cent.*^ 

Similar  returns  for  the  Amherst  graduating  class  of  1891  showed 
a  gain  by  the  nonusers  of  tobacco  of  24  per  cent  in  weight,  of  37  per 
cent  in  height,  and  of  42  per  cent  in  growth  of  chest.  In  lung  capac- 
ity the  tobacco  users  had  lost  2  cubic  inches  of  air  space,  while  the 
nonusers  had  gained  6^  cubic  inches. 

The  somewhat  injurious  effect  of  tea,  coffee,  and  condiments, 
though  less  than  many  other  evils,  should  be  included  in  any  list 
of  the  imperfections  in  respect  to  hygiene  of  existing  habits  of  life. 

Section  6. — Activity  hygiene. 

Only  a  generation  ago  there  were  scarcely  any  gymnasia  in  this 
country,  but  to-day  the  importance  of  regular  exercise  and  bathing  is 
recognized  by  everyone.  This  is  far  from  saying,  however,  that  this 
important  method  of  conserving  our  vital  resources  has  more  than 
begun  to  be  exploited. 

First,  the  bath  for  the  well-to-do,  and,  latterly,  the  public  baths  for 
the  poor,  have  given  all  an  opportunity  to  obtain  the  cleansing  and 
healing  agency  of  water.  And  in  recent  years  the  application  of 
baths  has  become  a  science.* 

Baths  may  be  used  as  social  agents.  Judge  Ben.  B.  Lindsey,  of 
the  Denver  juvenile  court,  insists  that  every  child  must  take  a  bath 
before  appearing  in  the  court  room.     Neutral  baths,  1.  e.,  baths  regu- 

<^  Doctor  Anderson,  of  the  Yale  Gymnasium,  finds  similar  results.  He  also 
points  out  a  statistical  pitfall  into  which  some  investigators  have  fallen.  This 
is  the  common  statistical  fallacy  of  selection.  There  are  two  great  groups  of 
college  students,  roughly  distinguished  as  athletes  and  scholarship  men,  (See 
Doctor  Sargent,  "  Physique  of  scholars,  athletes,  and  the  average  student," 
Popular  Science  Monthly,  September,  1908.)  Smoking  is  more  common  in  the 
former  group.  They  are  not  athletes  because  they  smoke,  but  smoke  because 
they  are  athletes.  The  raw  figures  of  smokers  and  nonsmokers  usually  show 
that  the  smokers  have  better  physical  development,  but  if  we  compare  the 
smoking  athletes  with  the  nonsmoking  athletes  and  the  smoking  scholarship 
men  with  the  nonsmoking  scholarship  men  the  results  are  quite  different.  For 
similar  statistical  fallacies,  due  to  failure  to  subgroup  properly,  see  Mayo- 
Smith,  "  Statistics  and  Sociology,"  Macmillan,  1895. 

*  See  J.  H.  Kellogg,  M.  D.,  "  Rational  Hydrotherapy,"  Philadelphia,  1904. 


REPORT   ON    NATIONAL.  VITALITY.  91 

lated  to  the  temperature  of  the  body,  have  been  found  valuable  in 
relaxing  the  nerves  of  the  body,  and  even  in  the  treatment  of  mental 
disease. 

As  to  exercise,  a  healthy  organism  must  call  into  play  every  func- 
tion daily,  both  mental  and  physical.  One  of  the  evils  of  the  division 
of  labor  which  civilization  has  brought  is  that  the  sedentary  worker 
does  not  have  enough  physical  exercise,  but  too  much  mental  exercise, 
while  the  situation  is  just  the  opposite  in  the  case  of  the  workingman. 

A  well-known  physical  director,  now  nearly  50  years  old,  writes  me 
that  he  has  this  year  taken  up  systematic  physical  training,  which 
he  has  neglected  for  several  years  because  of  pressure  of  work.  As 
a  result  his  weight  has  risen,  his  chest  and  arm  girths  have  increased, 
while  his  waist  girth  has  decreased,  and  he  is  conscious  of  decided 
improvement  in  memory  and  in  sleep.  This  instance  is  cited  as  an 
example  of  the  physical  development  possible  in  a  man  of  middle 

In  its  bearing  on  exercise,  the  growth  of  modern  athletics  and  its 
effects  on  the  physical  ideals  of  men  and  women  is  to  be  welcomed. 
The  revival  of  the  Olympian  games  and  the  spread  of  popular  par- 
ticipation in  such  outdoor  sports  as  golf,  tennis,  boating,  and  horse- 
back riding  have  all  had  their  share  in  building  up  a  new  health 
ideal.  Thus  we  are  getting  away  from  the  mediaeval  idea  of  morti- 
fication of  the  flesh  and  aj)proaching  more  closely  the  Greek  concep- 
tion of  a  beautiful  body  as  the  covering  for  a  beautiful  soul.  The 
Greeks  lifted  their  sports  to  a  higher  level  than  ours  by  surrounding 
them  with  imagination  and  making  them  a  training  in  assthetics  as 
well  as  in  physical  excellence.'*  The  American  idea  is  at  present  too 
closely  connected  with  mere  winning,  and  not  enough  with  develop- 
ment. In  the  past  the  physical  athlete  has  been  too  much  associated 
with  the  pugilist,  and  has  been  looked  down  upon  as  having  merely 
brute  strength.  The  intellectual  type,  on  the  other  hand,  has  been 
content  wholly  to  neglect  bodily  development. 

In  the  last  three  years  considerable  evidence  has  accumulated  to 
show  that  the  sitting  posture  of  the  sedentary  man  tends  sooner  or 
later  to  produce  nervous  prostration,  and  that  the  ordinary  chair 
invites  to  this  effect  by  producing  a  bent  attitude,  both  in  the  forward 
direction  and  in  the  shoulders.  The  effect  of  the  former  is  to  tax 
the  splanchnic  nerves  and  congest  the  portal  circulation.  The 
splanchnic  area,  which  is  enormous,  is  a  sort  of  overflow  tank  for  the 
blood.  If  the  muscles  of  this  area  are  allowed  to  relax  through  im- 
proper position  in  standing  or  sitting,  the  result  is  the  stagnation 
of  the  blood  in  the  abdomen,  and  this  in  turn  results  in  a  vicious 
circle  of  evil  effects.  Since  much  of  our  life  is  spent  in  chairs,  this 
fact  is  of  no  small  importance.  Improperly  made  school  chairs  and 
unhygienic  habits  of  sitting  in  them  may  start  off  millions  of  young 
lives  with  round  shoulders,  curved  spines,  and  the  later  effects  of 
portal  congestion. 

Exercise  of  mind  does  not  simply  mean  exercise  of  intellect.  The 
emotions  and  the  will  are  equally  a  part  of  a  well-developed  healthy 
man.  Late  in  life  Darwin  had  occasion  to  lament  the  fact  that  his 
emotional  capacity  had  become  cramped  because  he  had  exercised 

« See  G.  L.  Dickinson:  "The  Greelj  View  of  Life,"  New  York  (McClure, 
Phillips),  1906,  pp.  131-134. 


92  EEPOET   OlSr   NATIONAL  VITALITY. 

his  mind  in  his  own  branch  of  work  to  the  exclusion  of  other  things. 
Whatever  our  ideas  of  theology  or  religion  are,  it  is  true  that  we  all 
ought  to  have  a  spiritual  sense.  Some  men  lack  this  spiritual  sense 
and  are  incapable  of  understanding  the  spiritual  experience  of  others. 
"  For  toil  without  purposeful  and  occupied  leisure  is  unfilled  pur- 
j)ose,  a  process  arrested  midway."  ^  Worry  and  fear  are  unhealthy. 
Hope,  courage,  enjoyment,  and  an  optimistic  attitude  generally  are 
healthy.^ 

The  ordinary  workingman  works  two  or  three  hours  too  much 
every  day.  Nearly  every  man  overworks  himself,  takes  insufficient 
rest  and  recreation,  and  worst  of  all,  cuts  off  his  normal  portion  of 
sleep.  Fatigue  ought  to  be  "  avoided  like  poison,"  because,  physio- 
logically, it  is  really  poison.  Worry,  fear,  and  anger  also  produce 
poisons  harmful  to  the  human  body.  This  is  suggested  at  least  by 
the  effect  upon  a  nursing  infant  of  violent  paroxysms  of  anger,  or 
periods  of  intense  fear  or  anxiety  on  the  part  of  its  mother.  The 
intense  exhaustion  which  follows  such  paroxysms  is  another  case  in 
point. 

An  animal  lives  a  much  more  healthy  life  than  the  average  man, 
because  an  animal  follows  instinct,  while  a  man  to  a  large  extent 
endeavors  to  substitute  for  his  instincts  rules  which  are  very  often 
false.  One  of  the  instincts  constantly  disregarded  by  man  is  that 
which  finds  its  expression  in  fatigue.  The  ordinary  man  working 
for  some  one  else  is  compelled  to  toil  beyond  the  fatigue  limit;  and, 
on  the  other  hand,  if  a  man  is  in  business  for  himself,  he  does  the 
same  thing  of  his  own  will.  Although  no  one  knows  what  sleep  is, 
it  serves,  according  to  the  best  theory,  to  eliminate  poisons  and  to 
rebuild  tissue.  With  rest  is  closely  associated  recreation.  Play 
practices  the  power  of  a  child's  mind,  while  contest  among  children 
develops  self-control.*'  Similarly,  adults  are  rested  by  play  or  recrea- 
tion, their  minds  and  bodies  are  relaxed,  while  their  contests  of  mimic 
warfare  develop  their  powers  of  will  and  effort. 

Section  7. — Sex  hygiene. 

One  element  in  personal  hygiene  concerns  the  sex  relation.  This 
can  not  be  treated  under  other  heads,  for  the  sex  relation  is  so  purely 
a  personal  and  individual  one.  From  its  normal  utilization  there  is 
little  to  fear,  but  from  the  effects  of  illegitimate  sexual  practices  the 
world  suffers  enormous  yearly  losses.  It  is  hardly  possible  to  have 
promiscuous  sex  relations  out  of  wedlock  without  contracting  one  or 
the  other  of  the  serious  venereal  diseases.  The  best  authorities  report 
that  "  every  prostitute  is  diseased  some  of  the  time  and  some  prosti- 
tutes are  diseased  all  of  the  time." 

One  disease,  syphilis,  infects  the  blood  and  therewith  all  parts  of 
the  body.     For  months  after  infection  with  this  disease  the  indi- 

«>  Simon  N.  Patten  :  "  The  New  Basis  of  Civilization,"  New  York  (Macmillan), 
1907,  p.  158. 

*  Du  Bois :  "  The  Psychic  Treatment  of  Nervous  Disorders,"  New  York,  1905, 
465  pp.  Saleeby:  "Worry,  the  Disease  of  the  Age,"  New  York  (Stokes),  1907. 
Sidis:  "The  Psychology  of  Suggestion,"  New  York  (Appleton),  1899,  386  pp. 
Schofield :  "  The  Force  of  Mind,  or  the  Mental  Factor  in  Medicine,"  London 
(Churchill),  1902,  309  pp. 

'^  See  President  G.  Stanley  Hall :  "  Play  and  Dancing  for  Adolescents,"  Inde- 
pendent, reprinted  in  "  Mind  and  Body,"  Vol.  XIV,  1907,  pp.  43-48. 


BEPORT    ON    NATIONAL   VITALITY.  93 

vidual  may  communicate  it  by  a  kiss  as  well  as  by  cohabitation ;  and 
articles  moistened  by  his  secretions — towels,  drinking  glasses,  pipes, 
etc. — may  also  convey  the  infection.  While  under  proper  treatment 
the  disease  is  not  always  dangerous  to  life  in  the  earlier  years,  yet 
the  possibilities  of  transmitting  the  contagion  should  forbid  marriage 
for  at  least  three  years. 

The  most  serious  results  of  syphilis,  some  authorities  say,  may 
appear  years  after  its  acquisition,  when  the  individual  has  been 
lulled  into  a  false  sense  of  security  by  long  freedom  from  its  mani- 
festations and  considers  himself  cured.  Many  cases  are  practically 
incurable.  Some  are  fatal  in  sjDite  of  treatment.  It  may  attack  any 
organ  of  the  bod3^  Among  the  many  diseases  to  which  it  may  lead 
are  apoplexy,  paralysis,  insanity,  and  locomotor  ataxia;  and  these 
often  appear  after  the  man  has  acquired  a  family  that  is  dependent 
upon  him  for  support. 

The  leading  insurance  companies  refuse  to  insure  the  life  of  a 
syphilitic  person  for  four  or  five  years  after  the  disease  was  con- 
tracted, and  then  only  upon  special  terms,  for  their  records  prove 
that  syphilis  shortens  life. 

That  the  syphilitic  parent  may  transmit  the  disease  to  his  offspring 
is  common  knowledge.  Some  of  his  children  are  destroyed  by  the 
inherited  disease  before  birth;  others  are  born  to  a  brief  and  sickly 
span  of  life;  others  attain  maturity,  seriously  handicapped  in  the 
race  of  life  by  a  burden  of  ill  health,  incapacity,  and  misery  produced 
by  the  inherited  taint,  while  still  others  escape  these  evil  effects." 

Forel,  in  Die  Sexuelle  Frage,  shows  that  even  Weissmann  does  not 
deny  the  possibility  of  poisoning  the  germ  cell  and  so  transmitting 
some  "  acquired  characteristics,"  as  in  alcoholism  and  venereal  poison- 
ing. One  of  the  saddest  facts  in  both  cases  is  that  the  parent  may- 
escape  and  the  children  reap  the  results  in  insanity,  tendency  to  con- 
sumption, and  prostitution. 

Another  disease — 

Gonorrhea,  while  usually  cured  without  apparent  -loss  of  health,  has  always 
serious  possibilities ;  it  kills  about  1  in  200 ;  it  impairs  the  sexual  power  and 
fertility  of  a  much  larger  number ;  it  often  produces  urethral  strictures,  which 
later  may  cause  loss  of  life.* 

The  persistence  of  gonorrhea  in  the  deeper  parts  long  after  it  is  outwardly 
cured  leads  to  the  unsuspected  communication  of  the  disease  to  women  with 
whom  the  individual  may  cohabit.  Much  of  the  surgery  performed  upon  women 
has  been  rendered  necessary  by  gonorrhea  contracted  from  the  husband.  Should 
she  while  infected  with  this  disease  give  birth  to  a  child,  the  baby's  eyes  may 
be  attacked  by  the  infection,  sometimes  with  immediate  loss  of  sight.  Probably 
25  per  cent  *  of  the  blindness  of  children  is  thus  caused. 

Dr.  Prince  A.  Morrow  says : 

This  social  danger  comes  from  frequent  introductions  of  these  diseases  into 
marriage.  The  frequency  of  marital  contamination  does  not  admit  of  exact 
mathematical  expression,  as  both  social  sentiment  and  professional  ethics  unite 
to  cover  up  and  conceal  it.  Possibly  10  per  cent  of  men  who  marry  infect  their 
wives  with  venereal  disease. 

"  Circular  No.  2,  "  Self-protection,"  Chicago  Society  of  Social  Hygiene,  pp.  7-8. 

*  "  The  average  of  a  great  many  statistics  shows  that  one-fourth  of  all  blind 
persons  owe  their  affliction  to  the  effects  of  ophthalmia  of  the  new  born."  Chas. 
H.  May,  M.  D.,  ophthalmic  and  aural  surgeon,  New  York,  Transactions  of  Ameri- 
can Societies  of  Sanitary  and  Moral  Prophylaxis,  Vol.  II,  1908. 


94  REPORT   ON   NATIONAL  VITALITY. 

The  report  of  the  Committee  of  Seven  (New  York)  shows  that  in 
private  practice  nearly  30  per  cent  of  venereally  infected  women  were 
contaminated  by  their  husbands.  The  report  of  the  Committee  on 
Sanitary  and  Moral  Prophylaxis  (Baltimore)  shows  that  nearly  40 
per  cent  of  the  infections  in  women  seen  in  private  practice  were  com- 
municated in  married  life.  "  My  own  observations  at  the  New  York 
Hospital,  extending  over  a  period  of  several  years,  would  indicate 
that  fully  70  per  cent  of  all  women  who  came  there  for  treatment  of 
syphilis  were  respectable  married  women  who  had  been  infected  by 
their  husbands."  ^ 

Observation  shows  that  gonorrhea  is  markedly  intensified  in  viru- 
lence and  danger  to  the  woman  in  fulfilling  the  functions  for  which 
marriage  was  instituted.  Pregnancy  and  childbearing  open  the  way 
for  germs.  One  of  the  most  constant  effects  of  gonorrhea  in  women 
is  permanent  and  irremediable  sterility.  Fifty  per  cent  of  gonor- 
rheally  infected  women  become  absolutely  sterile,  and  a  still  larger 
percentage  sterile  after  the  first  child  is  born  (one-child  sterility). 
Noeggerath  found  in  81  gonorrheal  women  49  entirely  sterile.  In  80 
sterile  marriages  Kehrer  found  45  caused  by  inflammatory  changes  of 
gonorrheal  origin.  It  is  estimated  that  the  husband  is  directly  re- 
sponsible for  20  to  25  per  cent  of  sterility  from  his  inability  to  pro- 
create as  the  result  of  gonorrhea.  In  addition  the  husband,  though 
not  sterile  himself,  may  infect  his  wife,  rendering  her  sterile.  The 
disease  is  ultimately  responsible  for  about  TO  to  75  per  cent  of  all 
sterility  in  married  life,  which  is  not  of  choice,  but  of  incapacity. 
Lier-Ascher's  careful  statistics  place  this  proportion  at  71.2  per  cent. 
These  figures  relate  to  absolute  sterility.  The  chief  social  danger  of 
gonorrhea  as  a  depopulating  factor  is  the  creation  of  secondary  steril- 
ity, or  what  has  been  expressively  termed  "  one-child  sterility."  The 
large  percentage  of  marriages  in  which  one  child  represents  the  total 
fecundity  of  the  family  justifies  the  conclusion  that  this  sterility  is 
in  many  cases  not  of  choice,  but  of  procreative  capacity  extinguished 
by  gonorrhea. 

In  addition,  the  inflammation  set  up  in  the  maternal  organs  may 
render  the  mother  a  permanent  invalid  or  compel  her  to  submit  to  a 
mutilating  operation  to  save  her  life. 

Gynecologists  furnish  statistical  evidence  showing  that  80  per  cent 
of  the  deaths  due  to  inflammatory  diseases  peculiar  to  women  ^  and 
about  70  per  cent "  of  all  the  work  done  by  specialists  for  diseases  of 
women  is  caused  by  gonorrhea. 

In  addition  to  the  effect  of  a  low  protein  diet  on  endurance,  already 
discussed,  and  on  general  health,  its  relation  to  the  sexual  life  should 
be  mentioned.  Experiments  on  this  subject  seem  to  show  that  exces- 
sive meat  eating  and  excessive  protein  intake  tend  to  irritate  the 
sexual  organs  and  to  produce  abnormal  sexual  desire  just  as  they  do 

(^  Morrow,  "Social  Diseases  and  Marriage,"  Philadelphia  (Lea),  1904. 

*  In  report  of  special  committee  of  the  American  Medical  Association,  1901, 
Hunniston  says :  "  Ninety  per  cent  of  inflammatory  troubles  of  maternal  organs 
are  attributable  to  gonorrhea."  Price  says :  "  That  in  over  1,000  operations  for 
pelvic  trouble  95  per  cent  were  attributable  to  this  infection."  Another  author- 
ity gives  a  percentage  of  75. 

<'  Address  of  Doctor  Cleveland,  president  of  American  Gynecological  Society, 
at  National  Congress  of  American  Physicians  and  Surgeons,  Washington,  1907, 


EEPORT   ON    NATIONAL  VITALITY.  95 

a  desire  for  alcoholic  stimulation.    This  fact  is  of  importance  in  pre- 
venting secret  vice  among  the  young. 

Thanks  to  the  efforts  of  a  few  farsighted  men  like  Dr.  Prince  A. 
Morrow,  Prof.  C.  R.  Henderson,  and  Mr.  Edward  Bok,  these  subjects 
are  being  given  some  of  the  publicity  they  deserve.  Reticence  on 
these  subjects  is  justified  only  so  far  as  it  makes  for  youthful  inno- 
cence. But  ignorance  is  not  innocence;  on  the  contrary  it  is  the 
surest  road  to  guilt. 

Section  8.- -Personal  hygiene  in  general. 

Personal  hygiene  is  only  beginning  to  be  generally  exploited.  Most 
persons  leave  their  health  to  be  attended  to  by  physicians  and  health 
officers,  just  as  many  people  leave  their  religion  in  the  hands  of  a 
priest  or  clergyman.  So  far  as  practiced  at  all,  personal  hygiene  has 
been  confined  chiefly  to  invalids  and  athletes.  Even  by  them  it  is 
usually  practiced  to  tide  over  an  illness  or  to  prepare  for  a  contest. 
But  it  is  manifest  destiny  that  a  wise  economy  of  vitality  will  sooner 
or  later  be  practiced.  Waste  of  vital  resources  is  as  irrational  as 
waste  of  natural  resources.  Neither  is  inexhaustible  and  both  must  be 
conserved.  Thoughtlessness  and  ignorance  are  the  reasons  for  the  ap- 
palling waste  of  both  now  going  on.  Even  people  who  do  not  defi- 
antly abuse  their  strength  by  definite  excesses  are  liable  to  waste  it 
gradually.  Slightly  unhygienic  habits  grow,  and  their  effects  are 
doubtless  cumulative.  It  is  well  known  that  even  a  so-called  "  venti- 
lated house,"  if  lived  in  long  enough  without  sufficient  outdoor  life, 
may  induce  tuberculosis.  This  must  be  through  the  repetition  of  an. 
infinitesimal  injury  produced  through  each  respiration  eighteen  times 
a  minute  for  twenty-four  hours  a  day  for  half  a  lifetime. 

So  with  the  use  of  food  preservatives.  Food  manufacturers  have 
laid  much  emphasis  on  the  fact  that  preservatives  are  "  harmless  " 
because  used  in  small  quantities,  but  Doctor  Wiley  has  raised  the 
question  whether  even  very  small  quantities  of  these  preservatives, 
if  used  continuously  for  a  sufficient  length  of  time,  are  not  injurious. 
The  same  applies  to  the  repetition  of  preservatives  in  a  large  number 
of  different  foods.  If  only  one  particular  food  contained  a  preserva- 
tive, the  effect  would  be  relatively  negligible;  but  as  one  food  after 
another  has  become  adulterated,  the  human  stomach  is  made  the  daily 
receptacle  of  many  times  the  "  harmless  "  amount  in  any  one  par- 
ticular food.  The  obstacles  to  hygiene  which  have  accumulated  with 
civilization  are  almost  as  numerous  and  as  small  as  the  barnacles 
which  impede  a  ship.  To  remove  them  is  in  large  part  to  "  return  to 
nature."  Many  of  the  inventions  of  which  civilization  boasts  have 
had  an  unhygienic  side.  The  invention  of  houses  has  made  it  pos- 
sible for  mankind  to  spread  all  over  the  globe,  but  it  is  responsible 
for  tuberculosis,  especially  after  glass  was  devised,  which  while  let- 
ting in  the  light  keeps  out  the  air.  The  invention  of  cooking  and 
preparing  foods  has  widened  the  variety  of  man's  diet,  but  has  led  to 
the  decay  of  his  teeth."^    The  invention  of  the  alphabet  and  printing 

°'  See  Ottofy,  "  The  Teeth  of  the  Igorots,"  Dental  Cosmos,  July,  1908,  where 
it  is  shown,  statistically  speaking,  that  the  teeth  of  Americans  are  "  ten  times  as 
bad  as  those  of  the  Igorots,"  while  the  civilized  Filipinos  have  teeth  as  bad  as 
those  of  Americans. 


96  REPORT   ON    NATIONAL.  VITALITY. 

has  made  possible  the  accumulation  of  knowledge,  but  it  has  produced 
eye  strain  with  all  its  attendant  evils.  The  invention  of  chairs  has 
added  to  human  convenience,  but  has  led  to  spinal  curvature  and 
abdominal  congestion.  The  device  of  a  division  of  labor  has  added 
to  wealth,  but  has  destroyed  the  normal  balance  of  mental  and  phys- 
ical work,  recreation,  and  rest.  Similar  fault  may  be  found  with 
clothing,  especially  corsets,  shoes,  and  hats,  and  with  numerous  other 
contrivances.  Yet  it  would  be  foolish,  even  if  it  were  i)ossible,  to 
attempt  to  "  return  to  nature  "  in  the  sense  of  abolishing  civilization. 
We  must  not  go  backward,  but  forward.  The  cure  for  eye  strain  is 
not  in  disregarding  the  invention  of  reading,  but  in  introducing  the 
invention  of  glasses.  The  cure  for  tuberculosis  is  not  in  the  destruc- 
tion of  houses,  but  in  devices  for  ventilation.  It  is  a  little  knowledge 
that  is  dangerous.  Civilization  can,  with  fuller  knowledge,  bring  its 
own  cure  and  make  the  "  kingdom  of  man  "  far  larger,  even  in  respect 
to  hygienic  conditions,  than  "  nature  "  people  can  ever  dream  of. 

Unhygienic  customs  and  fashions  are  exceedingly  slow_  to  yield, 
but  they  do  yield  in  the  end.  It  should  be  the  part  of  intelligent  men 
to  lead  in  hygienic  reform,  not  by  intolerant  and  impatient  abuse  of 
their  fellow-men,  but  by  the  quiet  force  of  example.  The  intolerant 
and  impatient  reformer  does  incalculable  harm,  for  he  takes  no  ac- 
count of  that  subtle  perversity  of  human  nature  Avhich  resents  his 
interference.  Equally  harmful  is  the  man  who  seeks  only  to  imitate 
the  crowd,  who  condones  the  vices  of  his  time  and  country. 

But  we  must  always  bear  in  mind  what  has  been  called  the  "  psy- 
chology of  the  crowd."  Tarde,  Le  Bon,  Baldwin,  Eoss,  and  others 
have  shown  that  society  is  largely  ruled  by  customs  which  grow  out 
of  imitation.  In  order  that  any  social  custom  shall  be  changed, 
initiative  is  necessary.  The  upper  classes  should  take  the  lead,  for  any 
reform  will  spread  many  times  more  quickly  when  the  initiative  comes 
from  above  than  when  it  comes  from  below.  Western  civilization  has 
made  its  marvelously  rapid  progress  in  Japan  for  the  simple  reason 
that  the  Mikado  approved,  and  marvelously  slow  progress  in  China 
for  the  simple  reason  that  the  Empress  disapproved. 

We  find  the  same  principle  at  work  in  the  progress  of  medicine. 
Hydrotherapy  originated  with  a  peasant  and  required  three  centuries 
to  come  into  vogue.  The  use  of  sour  milk,  on  the  other  hand,  has  been 
advocated  only  during  the  last  two  or  three  years,  but^  the  initiative 
came  from  ]\letchnikoff,  one  of  the  foremost  of  medical  scientists. 
The  consequence  is  that  the  so-called  "sour-milk  craze"  has  already 
led  to  great  industries  and  affected  the  business  of  groceries,  soda- 
water  fountains,  and  even  liquor  saloons. 

The  change  constituting  hygienic  reform  will  be  brought  about  most 
rapidly  by  the  influences  on  the  young.  If  children  in  their  homes 
and  schools  are  given  proper  models  for  imitation,  the  public  opinion 
which  they  will  form  may  make  a  revolution  in  a  single  generation. 
Anyone  who  realizes  the  almost  resistless  force  of  the  principle  of 
imitation,  especially  when  applied  to  children,  will  receive  a  new  sense 
of  the  responsibility  he  takes  in  setting  an  example  to  the  young. 
There  are  three  classes  in  particular  on  whom  the  responsibility  is 
heavy — teachers,  physicians,  and  parents.  If  they  wish  the  child  to 
be  free  from  the  cigarette  habit,  they  must  sacrifice  the  cigar  and  pipe 
habit,  even  though  it  be  true  that  cigars  and  pipes  are  not  injurious  to 
adults.    They  may  believe  this,  but  the  children  will  not.    The  same 


REPORT    ON    NATIONAL   VITALITY.  97 

principle  applies  to  other  and  more  serious  infractions  of  the  laws  of 
health.  It  is  probably  through  the  love  of  the  next  generation,  rather 
than  through  any  selfish  care  for  the  present,  that  men  and  women 
now  living  will  take  the  most  pains  to  secure  the  best  results  in 
bringing  about  the  change  in  living  conditions  for  which  every 
hygienist  hopes. 

Chapter  X. — A7'e  hygienic  measures  eugenic? 

Section  1. — Prolongation  of  toeak  lives. 

We  have  discussed  two  factors  which  cooperate  to  produce  vitality, 
namely,  heredity  and  hygiene ;  and  two  corresponding  methods  of  im- 
proving vitalit}^,  namely,  by  utilizing  a  possible  science  of  eugenics 
on  the  one  hand  and  by  utilizing  the  existing  science  of  hygiene  on 
the  other.  The  question  now  arises,  Are  these  two  methods  in  conflict 
with  each  other  ?  It  is  charged  that  hygiene  prolongs  the  lives  of  unfit 
and  defective  classes.  We  have  already  seen  that  in  Indiana,  institu- 
tional care  of  the  insane  has  prolonged  the  average  insane  lifetime  by 
some  eight  years.     Referring  to  the  insane.  Dr.  Charles  Dana  says : 

For  twenty-five  years  the  explanation  of  this  increase  in  statistics  of  insanity 
has  been  that  more  cases  were  observed  and  more  victims  kept  in  institutions 
than  formerly ;  and  this  is  still  the  explanation.  It  is  my  opinion,  however, 
that  the  increase  is  a  real  one,  and  it  is  one  to  be  expected  not  only  from  the 
strenuousness  of  modern  life  and  increase  of  city  population,  but  also,  because 
more  feeble  children  are  nursed  to  maturity  and  more  invalid  adolescents  are 
kept  alive  to  propagate  weakly  constitutions  or  to  fall  victims  themselves  to 
alienation,  the  period  of  life  susceptible  to  insanity  is  longer. 

A  fourth  of  the  cases  of  insanity  is  due  to  so-called  "  moral  causes :  "  Emo- 
tional strain,  shocks,  and  vicious  indulgences.  But  moral  causes  are  not  sufficient 
to  cause  insanity  if  the  individual  has  a  strong  constitution.  Insanity  is  increased 
in  part,  then,  because  we  are  saving  too  many  lives  by  the  careful  regulations 
of  our  health  boards.  Hence,  those  who  are  working  so  enthusiastically  and 
nobly  and  successfully  in  preventing  disease  achieve  results  which  carry  serious 
responsibilities  for  the  State." 

It  is  true  that  we  prolong  the  lives  of  the  insane  and  defective 
classes,  and  that  they  thus  make  a  greater  burden  on  society.  We 
should  see  to  it  that  certain  of  these  classes  are  not  permitted  to  prop- 
agate their  kind.    This  point  has  been  explained  in  Chapter  VI. 

It  is  further  claimed  that  infant  mortality  is  but  the  operation  of 
natural  selection  and  should  not  be  interfered  with  if  we  are  to  keep 
up  the  vital  power  of  the  race.  Preventive  medicine  has  certainly 
prolonged  the  lives  of  infants  or,  at  any  rate,  of  children  in  general.* 
But  has  this  weakened  the  race?  It  is  pointed  out  that  the  mortality 
later  in  life  has  not  decreased,  and  that  in  some  cases  it  has  even 
tended  to  increase.  But  this  fact  can  be  explained  in  either  of  two 
ways.    One  is  on  the  hypothesis  of  the  extension  of  the  lives  of  weak 

<* "  Psychiatry  in  its  relation  to  the  other  sciences,"  by  Charles  L.  Dana,  M.  D., 
before  the  section  on  psychiatry  at  the  International  Congress  of  Arts  and 
Science,  at  St.  Louis,  September,  1904.  See  also  Janus  in  Modern  Life,  by  W.  M. 
Flinders-Petri,  New  York  (Putnam),  1907. 

^  See  Edwin  Graham,  "  Infant  mortality,"  .Journal  American  Medical  Asso- 
ciation, September  26,  1908 ;  also  Edward  B.  Phelps,  "  Statistical  study  of  infant 
mortality,"  Quarterly  Publications  American  Statistical  Association,  September, 
1908.  Mr.  Phelps  shows  that  infant  mortality  has  declined  less  than  is  com- 
monly believed,  and  that  its  apparent  decline  is  often  due  to  inaccurate  and 
misleading  statistics. 


98  REPORT    OlST    NATIONAL   VITALITY. 

infants.  The  other  is  on  the  hypothesis  of  the  comparative  neglect 
of  hygiene  among  adults.  It  is  surprising  that  tliis  latter  alternative 
has  not  been  given  due  consideration. 

Every  detail  of  infant  life  has  latterly  been  made  the  subject  of 
special  study,  and  every  mother  of  common  intelligence  has  tried  to 
learn  and  to  apply  the  results  of  that  study.  The  times  of  the  baby's 
meals,  the  quantity  of  its  feeding,  the  modification  and  sterilization  of 
cow's  milk,  the  hours  of  sleep,  the  ventilation  of  sleeping  rooms,  and 
other  innumerable  details  are  now  attended  to  with  scrupulous  care. 
The  change  in  these  respects,  even  within  the  memory  of  most  persons 
now  living,  is  striking.  The  children  have  reaped  the  reward.  But 
no  corresponding  change  has  taken  place  in  the  habits  of  the  adult 
population.  Many  families  buy  one  grade  of  milk  for  the  babies, 
and  another  cheaper  grade  for  the  rest  of  the  family.  This  they  re- 
gard as  "  econom}^"  Parents  require  their  children  to  keep  regular 
and  suitable  hours  for  sleep,  but  "  owl  it "  themselves.  They  will 
keep  their  children  out  of  doors,  and  send  them  into  the  country,  but 
subject  themselves  to  the  dust,  smoke,  and  close  air  of  the  workroom 
and  places  of  business.  They  w^ill  not  allow  their  children  to  use 
alcohol  or  tobacco,  or  even  tea  or  coffee,  much  less  opium,  chloral,  or 
other  habit- forming  drugs,  but  they  take  these  themselves  as  a  matter 
of  course.  The}^  are  now  insisting  on  playgrounds  for  children,  but 
their  own  amusements  are  sought  in  the  unhygienic  theater,  or  majT'be 
in  the  saloon  or  immoral  resort.  The  child  is  protected  on  all  sides, 
with  the  result  that  he  sometimes  lives  almost  an  ideal  animal  life, 
with  its  due  proportion  of  amusement,  exercise,  rest,  and  sleep.  The 
parents  themselves  are  tied  down  to  drudgery,  overwork,  worry,  and 
long  hours.  The  difference,  when  we  reflect  upon  it,  is  startling.  We 
make  hygiene  paramount  for  our  children;  for  ourselves  we  neglect 
it  totally,  partly  from  the  idea  of  sacrificing  ourselves  for  the  sake  of 
our  children,  partly  from  necessity,  real  or  imagined,  and  partly 
from  the  thraldom  of  habit  already  formed.  With  such  a  contrast 
between  the  recent  improvement  of  hygiene  in  childhood  and  the  lack 
of  improvement  in  middle  life,  one  need  not  wonder  that  the  mor- 
tality of  one  period  has  improved  and  that  of  the  other  has  not.  We 
do  not  need  to  invoke  the  aid  of  the  theory  that  weak  lives  have  been 
more  prolonged  than  strong  lives.  The  moral  is  that  hygiene  should 
not  stop  in  childhood.  It  is  natural  and  proper,  however,  that  the 
first  attempt  to  apply  hygienic  knowledge  should  begin  with  children. 
It  is  through  children  that  new  ideas  usually  make  their  way  into 
custom.  "  You  can't  teach  an  old  dog  new  tricks."  Grown  persons 
have  habits  already  formed,  and  when  once  a  habit  is  formed  it  is 
difficult  to  change  it. 

Habits  of  living  among  adults  have  even  grown  worse  in  some 
respects.  Observing  practitioners  comment  on  the  increasing  nervous 
tension  in  modern  life.  The  rush  of  the  railway  train,  the  telephone, 
the  elevator  are  at  once  an  outgrowth  and  an  excitant  of  this  in- 
creased tension.  They  are  life's  pace  makers,  and  the  pace  is  ever 
quickened.  The  health  oificer  of  New  York  City  attributes  to  this 
severer  strain  the  increase  of  heart  and  nervous  diseases.  It  would 
be  interesting  to  know  the  relative  prevalence  of  adult  diseases  under 
conditions  of  reposeful  and  exciting  surroundings  and  occupations, 
but  I  know  of  no  investigation  on  this  phase  of  the  subject. 


EEPORT   ON   NATIONAL  VITALITY.  99 

While  this  report  was  being  written  the  recent  figures  from  Great 
Britain  came  to  hand.  The}^  show  that  the  tendency  of  the  death 
rates  among  the  later  ages  to  increase  seems  to  have  given  place  to  a 
slightly  opposite  tendency.  The  expectation  of  life  at  ages  40,  60, 
and  80  during  the  decade  of  1891-1900  has  a  little  more  than  held 
its  own  as  compared  with  the  previous  decade. 

Section  2. — Children's  diseases  impair  both  fit  and  unfit. 

Another  point  needs  emphasis.  When  it  is  said  that  the  lives  of 
weak  infants  are  prolonged  it  is  commonly  overlooked  that  the  same 
causes  also  prolong  the  lives  of  the  strong,  and,  reversely,  that  un- 
hygienic conditions  which  tend  to  exterminate  the  weak  tend  also 
to  shorten  the  lives  of  the  strong.  Bad  hj^giene  is  merely  a  common 
handicap  for  all  classes.  The  burden  of  proof  is  upon  those  who 
claim  that  it  has  a  differential  effect  and  increases  the  process  of 
weeding  out  the  unfit.  This  weeding-out  process  goes  on  whether 
there  is  a  great  or  a  small  obstruction  to  overcome.  Bad  air  and 
children's  epidemics  are  the  common  environment  of  all.  While 
this  must  produce  a  greater  mortality,  it  remains  to  be  shown  that  it 
would  be  more  selective. 

That  a  high  infant  mortality  does  not  tend  to  lengthen  life,  but 
rather  to  stunt  all  life,  would  seem  to  be  indicated  by  the  evidence, 
so  far  as  it  can  be  interpreted.  Russia,  for  instance,  has  a  high 
infant  mortality.  If  the  statistics  are  to  be  trusted,  it  is  TO  per  cent 
greater  than  in  the  United  States;  yet  Moscow  and  St.  Petersburg 
have  a  general  mortality  rate  which  greatly  exceeds  that  of  similar 
cities  in  this  country. 

It  may  be  that  the  more  unfavorable  the  struggle  for  existence 
the  more  rapidly  will  natural  selection  result  in  improved  vitality. 
But  even  if  this  were  true,  it  would  not  imply  that  in  a  more  favor- 
able environment  selection  would  cease.  And  it  may  not  be  true.  It 
may  be  that  adversity,  if  too  severe,  will  crush  and  injure  the  sur- 
vivor as  well  as  eliminate  the  unfit.  We  do  not  look  for  the  best 
trees  on  the  bleak  mountain  top,  but  in  the  ge"nial  valley.  As  we  go 
up  the  struggle  for  existence  increases,  until  even  the  sturdiest  fail 
to  thrive  above  the  "  timber  line." 

The  farmer  who  tries  to  improve  his  stock  does  not  select  hardships.  Cold 
and  starvation  are  now  negligible  quantities  in  the  great  ranches,  and  the  breeds 
that  were  notable  for  ability  to  withstand  them  give  way  to  varieties  that  may 
be  adapted  to  neither  emergency.* 

Venereal  diseases,  hook-worm  disease,  malaria,  and  many  other 
maladies  shorten  and  weaken  life,  whether  of  weak  or  strong.  Re- 
ferring to  the  racial  degeneration  probably  caused  by  malaria  on  the 
sturdy  Greek,  Maj.  Ronald  Ross  said,  in  an  address  before  the  Oxford 
Medical  Society,  November  29,  1906 :  ^ 

Now  what  must  be  the  effect  of  this  ubiquitous  and  everlasting  incubus  of 
disease  on  the  people  of  modern  Greece?  Remember  that  the  malady  is  essen- 
tially one  of  infancy  among  the  native  population.  Infecting  the  child  one  or 
two  years  after  birth,  it  persecutes  him  until  puberty  with  a  long  succession  of 
febrile  attacks.     *     *     *     Imagine  the  effect  it  would  produce  upon  our  own 

<^  Simon  N.  Patten,  "The  New  Basis  of  Civilization,"  New  York  (Macmillan), 
1907. 

*  This  quotation  is  from  Dr.  L.  O.  Howard's  report  to  the  Conservatioh  Com- 
mission on  "  Economic  loss  to  the  people  of  the  United  States  through  insects 
that  carry  disease." 


100  KEPOET   ON    NATIONAL  VITALITY. 

children  here  in  Britain.  *  *  *  What  would  be  the  effect  upon  our  popula- 
tion, especially  our  rural  population — upon  their  numbers  and  upon  the  health 
and  vigor  of  the  survivor?  It  must  be  enormous  in  Greece.  People  often  seem 
to  think  that  such  a  plague  strengthens  a  race  by  killing  off  the  weaker  individ- 
uals; but  this  view  rests  upon  the  unproven  assumption  that  it  is  really  the 
weaker  children  which  can  not  survive.  On  the  contrary,  experience  seems  to 
show  that  it  is  the  stronger  blood  which  suffers  most — the  fair,  northern  blood 
which  nature  attempts  constantly  to  pour  into  the  southern  lands.'^  If  this  be 
true,  the  effect  of  malaria  will  be  constantly  to  resist  the  invigorating  influx 
which  nature  has  provided;  and  there  are  many  facts  in  the  history  of  India, 
Italy,  and  Africa  which  could  be  brought  forward  in  support  of  this  hypothesis. 
*  *  *  In  prehistoric  times  Greece  was  certainly  peopled  by  successive  waves 
of  Aryan  invaders  from  the  north.  *  *  *  That  race  reached  its  climax  of 
development  at  the  time  of  Pericles.  *  *  *  Suddenly,  however,  a  blight  fell 
over  all.  Was  it  due  to  internecine  conflict  or  to  foreign  conquest?  Scarcely, 
for  history  shows  that  war  burns  and  ravages,  but  does  not  annihilate.  Thebes 
was  thrice  destroyed,  but  thrice  rebuilt.  Or  was  it  due  to  some  cause,  entering 
furtively  and  gradually  sapping  away  the  energies  of  the  race  by  attacking  the 
rural  population,  by  slaying  the  newborn  infant,  by  seizing  the  rising  genera- 
tion, and  especially  by  killing  out  the  fair-haired  descendant  of  the  original 
settlers,  leaving  behind  chiefly  the  more  immunized  and  darker  children  of  their 
captives,  won  by  the  sword  from  Asia  and  Africa?  *  *  *  i  can  not  imagine 
Lake  Kopais,  in  its  present  highly  malarious  condition,  to  have  been  thickly 
peopled  by  a  vigorous  race;  nor,  on  looking  at  those  wonderful  figured  tomb- 
stones at  Athens,  can  I  imagine  that  the  healthy  and  powerful  people  repre- 
sented upon  them  could  have  ever  passed  through  the  anaemic  and  "  splenomega- 
lous"  infancy  (to  coin  a  word)  caused  by  widespread  malaria.  Well,  I  venture 
only  to  suggest  the  hypothesis,  and  must  leave  it  to  scholars  for  confirmation 
or  rejection.  Of  one  thing  I  am  confident — that  causes  such  as  malaria,  dysen- 
tery, and  intestinal  entozoa  must  have  modified  history  to  a  much  greater  extent 
than  we  conceive. 

Evolution  in  human  society  is  a  wonderfully  complex  thing.  Sur- 
vival of  the  races  has  long  been  dependent  on  a  long  period  of  pro- 
tection of  children  by  parents,  and  may  in  future  even  depend  on 
protection  of  other  kinds.^ 

Section  3. — Fitness  is  relative  to  environment. 

Wliether  or  not  degeneration  is  actually  going  on  is  a  question  for 
■which  the  data  are  insufficient  for  us  to  form  an  intelligent  generaliza- 
tion. That  there  are  very  strong  forces  working  in  that  direction  can 
not  be  questioned,  but  there  are  also  very  strong  forces  working  in 
the  opposite  direction.  In  discussing  degeneration,  one  point  must 
be  borne  in  mind  which  has  often  been  forgotten  by  writers  on  the 
subject.  Man's  fitness  to  live  is  relative  to  the  environment  in  which 
he  is  to  live.  If  muscular  strength  decreases,  it  is  not  a  sign  of  de- 
generation, provided  muscular  strength  is  no  longer  needed.  One 
does  not  speak  of  hothouse  grapes  as  degenerates.  They  doubtless 
lack  the  hardy  characteristics  of  wild  grapes,  but  these  characteristics 
are  not  needed  in  a  hothouse. 

If  it  should  prove  true  that  in  some  directions  humanitarian  im- 
pulses betray  us  into  favoring  the  survival  of  the  unfit  and  their 
perpetuation  in  the  next  generation,  such  shortsighted  kindness  must 
be  checked.  But  all  the  dangers  of  perpetuating  vital  weaknesses  can 
be  avoided  if  proper  health  ideals  are  maintained.    For  when  such 

«  Physicians  maintain  that  some  diseases,  especially  typhoid  fever  and  pneu- 
monia, are  more  apt  to  attack  the  strong  than  the  weak. 

^  See  Prince  Kuropatkin,  "  Mutual  Aid  a  factor  in  Evolution,"  New  York 
(  McClure-Phillips ) ,  1902. 


EEPOKT   ON    NATIONAL  VITALITY.  101 

health  ideals  become  a  national  possession  fewer  weak  infants  will 
be  born  into  the  world.  This  will  come  about  in  three  ways :  First, 
marriage  and  "  sterilization  "  laws  will  reduce  the  number  of  mar- 
riages of  degenerates.  Secondly,  parents  will  be  more  careful  of 
transmitting  disease  or  weakness  to  their  offspring.  There  is  strong 
reason  to  believe  that  inheritance  depends  largely  upon  the  physical 
condition  of  both  parents  at  the  time  of  conception.  If  at  such  a  time 
either  parent,  or  both  parents,  are  in  a  state  of  intoxication  or  suf- 
ferers from  venereal  disease,  this  lack  of  hygiene  on  their  part  will 
affect  the  heredity  of  the  offspring.  Immorality,  which  practically 
means  lack  of  sex  hygiene,  never  strengthened  a  race ;  on  the  contrary 
it  has  been  the  most  potent  cause  of  race  extinction  (of  the  Hawaiians, 
Indians,  negroes,  and^  others).'^  Thirdly,  the  influence  of  higher 
ideals  of  health  and  vitality  will  tend  both  to  restore  the  attraction 
of  a  strong  and  beautiful  physique  to  its  rightful  place  among  the 
various  attractions  which  lead  to  marriage,  and  to  lessen  the  aUure- 
ments  of  such  extraneous  attractions  as  wealth. 

<»  See  F.  L.  Hoffman,  "  Race  Traits  and  Tendencies  of  the  American  Negro," 
Publications  of  American  Economic  Association,  Ch.  VII,  August,  1896. 


Part  IV.— RESULTS   OF   CONSERVING  LIFE. 

Chapter  XI. — Prolongation  of  life. 

Section  1. — Life  is  lengthening. 

We  have  already  seen  evidence  of  the  possibility  of  prolonging 
life :  In  Europe  the  life  span  is  double  what  it  is  in  India.  The  death 
rate  of  Dublin  is  over  twice  that  of  Amsterdam,  and  three  times  that 
of  rural  Michigan.  Again,  making  every  allowance  for  inaccuracies  of 
old  records,  we  have  strong  reason  to  believe  that  life  is  twice  as  long 
as  three  or  four  centuries  ago,  and  modern  accurate  records  show  that 
it  is  to-day  increasing  more  rapidly  than  ever.  The  rate  at  which 
this  lengthening  proceeds  per  century  is  shown  in  the  following 
table,  based  on  Chapter  I. 

Rate  of  lengthening  life  (in  years,  per  century). 


Country. 


Periods. 


Females. 


England 

Do 

France  

Prussia 

Denmark 

Sweden 

United  States: 

Massachusetts. 

Do 

India 


1838-1854  to  1871-1881,  or  30  years 
1871-1881  to  1891-1900,  or  20  vears 
1817-1831  to  1898-1903,  or  76  vears 
1867-1877  to  1891-1900,  or  23  years 
1835-1844  to  1895-1900,  or  57  years 
1816-1840  to  1891-1900,  or  67  years 

1789  to  1855,  or  66  years 

1855  to  1893-1897.  or  40  years 

1881  to  1901,  or  20  years 


From  this  table  we  observe : 

First.  That  the  rate  of  progress  is  extremely  variable  in  different 
countries.  It  is  perhaps  no  accident  that  the  maximum  rate  obtains 
in  Prussia,  which  is  probably  the  most  progressive  country  in  the 
discovery  and  application  of  scientific  medicine.  If  progress  con- 
tinues for  a  century  at  merely  the  present  rate,  human  life  in  Prus- 
sia will  be  twenty-five  to  twenty-nine  years  longer  than  at  present. 
The  average  rate  of  improvement  for  all  the  countries,  excepting 
India,  is  about  fifteen  years  per  century. 

Second.  It  is  noticeable  that  in  practically  all  cases  the  improve- 
ment is  more  among  females  than  males.  This  is  one  expression  of 
the  progress  which  womankind  is  now  making  in  all  lands. 

Third.  This  table,  as  well  as  the  estimate  of  Professor  Finkelnburg 
already  quoted,  shows  that  not  only  is  the  average  duration  of  human 
life  increasin.^,  but  that  the  rate  of  increase  is  also  increasing.  The 
estimate  of  Finkelnburg  that  the  lengthening  of  life  during  the  inter- 
val between  the  sixteenth  century  and  the  end  of  the  eighteenth  cen- 
tury was  from  eighteen  or  twenty  years  to  a  little  over  thirty  years 
shows  a  rate  of  increase  of  about  four  years  per  century.    During 

102 


REPORT   ON    NATIONAL  VITALITY.  103 

the  following  century  he  estimated  that  the  life  span  increased  from 
a  little  over  thirty  to  thirty-eight  or  forty  years,  or  about  nine 
years  per  century.  In  the  table  we  see  that  in  England  the  length  of 
life  was  increasing  in  the  middle  of  the  nineteenth  century  at  a  rate 
of  from  five  to  nine  years  per  century,  while  during  the  last  quarter 
it  was  increasing  at  from  fourteen  to  sixteen  years  per  century.  In 
Massachusetts  the  imperfect  data  indicate  that  life  lengthened  in  the 
first  half  of  the  eighteenth  century  at  the  rate  of  about  seven  years  a 
century.  The  indication  for  the  last  part  of  the  nineteenth  century 
is  that  it  increased  at  the  rate  of  fourteen  years  per  century. 

We  may  briefly  summarize  chronologically  the  general  rate  of 
increase  as  follows: 

Lengthening  of  human  life  per  century. 

Years. 

During  seventeenth  and  eighteenth  centuries 4 

During  first  three  quarters  of  the  nineteenth  century 9 

Present  rate  in  Massachusetts 14 

Present  rate  in  Europe 17 

Present  rate  in  Prussia 27 

Section  2. — Table  showing  further  practicable  prolongation. 

It  would  be  surprising  if  the  future  should  not  witness  a  further 
lengthening  of  human  life,  and  at  an  increasing  rate.  Of  course 
there  is  a  limit  to  the  further  increase  of  human  life,  but  there  is 
good  reason  to  believe  that  the  limit  is  still  far  off. 

The  following  table  "  shows  that  at  least  fourteen  years  could  be 
added  to  human  life  by  the  partial  elimination  of  preventable  diseases 
according  to  the  stated  ratios  of  preventability.  This  is  equivalent 
to  a  reduction  in  the  death  rate  of  about  25  per  cent.  The  table  is 
based  on  the  causes  of  death  given  in  the  census  volume  for  mortality 
statistics  for  1906.  These  causes  are  arranged  according  to  the  aver- 
age, or  rather  median,^  age  at  death  from  the  disease.  This  median 
age  is  given  in  the  second  column.  The  order  in  this  column  shows  at 
a  glance  the  successive  onslaught  of,  or  rather  fatality  from,  the  vari- 
ous causes  of  death.  The  table  shows  the  successive  bombardments  of 
disease  to  which  human  life  is  subject. 

The  third  column  gives  the  average  lost  "  expectation  of  life ;  " " 
that  is,  the  expectation  cut  off  by  each  particular  cause  of  death. 

The  fourth  column  represents  the  percentage  which  the  deaths  from 
each  particular  cause  bear  to  the  total  number  of  deaths  in  1906  in 
the  registration  area.  It  shows  the  relative  importance  of  the  differ- 
ent causes  of  death  in  the  present  death  rate,  but  has  no  reference  to 
the  age  at  death. 

The  fifth  column  contains  an  estimate,  made  by  physicians,  of  the 
ratio  of  preventability  of  deaths  from  each  cause  named. 

"  For  detailed  statement  in  regard  to  the  construction  of  this  table,  see  appen- 
dix to  this  chapter. 

^  By  the  "  median  "  age  at  death  is  meant  the  age  such  that  one-half  of  the 
deaths  occur  earlier  and  one-half  later  than  this  age.  The  "  median  "  is  a  species 
of  average,  but  differs  from  the  ordinary  arithmetical  average.  It  has  the  great 
advantage  of  ease  of  computation. 

<'  The  "  expectation  "  is  taken  from  the  figures  of  Abbott  for  Massachusetts, 
1893-1897,  and  is  the  average  of  expectation  of  males  and  females.  See  Report 
State  Board  of  Health  for  Massachusetts,  1898. 

84369— No.  30--09 8 


104 


BEPOET   ON   NATIONAL  VITALITY. 


The  items  in  the  sixth  column  are  found  by  multiplying  together 
those  in  the  fourth  and  fifth  columns,  and  express  the  percentage  which 
the  preventable  deaths  from  each  cause  named  bears  to  the  total  num- 
ber of  deaths  from  all  causes. 

The  seventh  and  last  column  gives  the  figures  for  which  the  table 
is  constructed,  namely,  the  amount  of  prolongation  of  life  which 
would  come  about  through  preventing  deaths  according  to  the  ratios 
of  preventability  in  column  5.  When  it  is  said  that  a  death  is  pre- 
ventable, it  is  not,  of  course,  meant  that  the  person  saved  from  it 
will  never  die,  but  merely  that  his  death  is  postponed.  The  term 
"  postponable  "  would  avoid  a  great  deal  of  confusion  on  the  subject. 

The  principle  on  which  the  last  column  is  constructed  is  simply 
the  principle  of  averages.  The  column  shows  the  prolongation  of 
life  which  would  be  caused  by  postponing  the  "  postponable  "  deaths 
by  the  amounts  indicated  in  column  3.  To  illustrate  this  princi- 
ple, suppose  ten  magnitudes  to  be  averaged  arithmetically,  and  that 
their  average  is  thirty.  To  fix  our  ideas,  we  may  suppose  these  ten 
magnitudes  to  be  represented  by  ten  lines  drawn  on  a  sheet  of  paper. 
It  is  evident  that  if  one  of  these  ten  lines  is  prolonged  the  average 
of  the  ten  will  be  thereby  increased  by  exactly  one-tenth  of  the  pro- 
longation of  that  one  line. 

Possible  prolongation  of  life. 


(1) 


Cause  of  death. 


(2) 

(3) 

6(4) 

(5) 

A. 

B. 

C. 

D. 
Ratio  of 
preventa- 

Deaths 
due  to 
cause 
named  as 
percent- 
age of  all 
deaths. 

bility  (post- 

Median 
age  of 
deaths 
from 
causes 

named. 

Expecta- 
tion of 
life  at 

median 
age. 

ponability), 
i.e.,  ratio  of 
"preventa- 
ble" deaths 
from  cause 
named  to 
all  deaths 

from  cause 

named. 

Years. 

Years. 

Per  cent. 

Per  cent. 

1 

50 

2 

40 

1 

50 

.55 

0 

1 

50 

.3 

0 

1 

50 

2.3 

40 

1 

50 

.1 

0 

a 

50 

.3 

70 

1 

50 

7.74 

60 

1 

50 

.8 

40 

1 

50 

1.1 

30 

X 

50 

2.4 

50 

1 

50 

.9 

40 

2 

54 

.3 

75 

2 

54 

1.6 

70 

3 

54 

.07 

40 

3 

54 

.06 

40 

3 

54 

1.4 

70 

3 

54 

.5 

60 

5 

54 

.01 

20 

8 

52 

.05 

45 

8 

52 

.19 

80 

23 

40 

.17 

75 

24 

39 

.08 

60 

24 

39 

.7 

50 

26 

38 

2 

85 

28 

a  37 

.2 

30 

(6) 
E=CD. 


Ratio  of 

'preventa 

ble"  deaths 

from  cause 

named  to 

all  deaths 

from  all 

causes. 


(7) 
F=BE. 

Years 
added  to 
average 
lifetime  if 
deathswere 
prevented 
in  the  ratio 
of  prevent- 
ability of 
column  5. 


of 


Premature  birth 

Congenital    malformation 

heart  (cyanosis) 

Congenital   malformations 

other  than  of  heart 

Congenital  debility 

Hydrocephalus 

Venereal  diseases 

Diarrhea  and  enteritis 

Measles 

Acute  bronchitis 

Broncho-pneumonia 

Whooping  cough 

Croup 

Meningitis 

Diseases  of  larynx  other  than 

laryngitis 

Laryngitis 

Diphtheria 

Scarlet  fever 

Diseases  of  lymphatics 

Tonsilitis 

Tetanus 

Tuberculosis    other    than    of 

lungs 

Abscess 

Appendicitis 

Typhoid  fever 

Puerperal  convulsions 


Per 


cent. 
0.8 


.92 


.21 

4.64 

.32 

.33 

1.2 

.36 

.22 

1.12 

.03 

.02 

.98 

.25 

.002 

.02 

.15 

.13 
.05 
.35 
1.7 
.06 


Years. 
0.4 


.46 


.11 
2.32 
.16 
.17 
.6 
.18 
.12 
.6 

.02 

.01 

.63 

.14 

.001 

.01 


.05 
.02 
.14 
.65 
.02 


"  "  Expectation  "  for  females. 

*  As  to  some  inaccuracies  in  this  column,  see  Appendix  to  this  chapter,  section  4. 


KEPORT   ON    NATIONAL  VITALITY. 
Possible  prolongation  of  life — Continued. 


105 


(1) 


Cause  of  death. 


26.  Puerperal  septicemia 

27.  Other  causes  incident  to  child- 

birth   

28.  Diseases  of  tubes 

29.  Peritonitis 

30.  Smallpox 

31.  Tuberculosis  of  lungs 

32.  Violence 

33.  Malarial  fever 

34.  Septicemia 

35.  Epilepsy 

36.  General,  ill  defined,  and  un- 

known causes  (including 
"heart  failure,"  "dropsy," 
and  "convulsions") 

37.  Erysipelas 

88.  Pneumonia    (lobar    and    un- 
qualified ) 

39.  Acute  nephritis 

40.  Pleurisy 

41.  Acuteyellowatrophy  of  liver.. 

42.  Obstruction  of  intestines 

43.  Alcoholism 

44.  Hemorrhage  of  lungs 

45.  Diseases  of  thyroid  body 

46.  Ovarian  tumor 

47.  Uterine  tumor 

48.  Rheumatism 

49.  Gangrene  of  lungs 

50.  Anemia,  leukemia 

51.  Chronic  poisonings 

62.  Congestion  of  lungs 

53.  Ulcer  of  stomach 

54.  Carbuncle 

55.  Pericarditis 

56.  Cancer  of  female  genital  organs 

57.  Dysentery 

58.  Gastritis 

59.  Cholera  nostras 

60.  Cirrhosis  of  liver 

61.  General  paralysis  of  insane 

62.  Hydatid  tumors  of  liver 

63.  Endocarditis 

64.  Locomotor  ataxia 

66.  Diseases  of  veins 

66.  Cancer  of  breast 

67.  Diabetes 

68.  Biliary  calculi 

69.  Hernia 

70.  Cancer  not  specified 

71.  Tumor 

72.  Bright's  disease 

73.  Embolism  and  thrombosis 

74.  Cancer  of  intestines 

75.  Cancer  of  stomach  and  liver... 

76.  Calculi  of  urinary  tract 

77.  Cancer  of  mouth 

78.  Heart  disease 

79.  Influenza 

80.  Asthma  and  emphysema 

81.  Angina  pectoris 

82.  Apoplexy 

83.  Cancer  of  skin 

84.  Chronic  bronchitis 

85.  Paralysis 


(2) 


Median 
age  of 
deaths 
from 
causes 
named. 


Fears. 
28 

31 
31 
31 
32 
33 
34 
34 
34 
36 


(3) 


Expecta- 
tion of 
life  at 

median 
age. 


Years, 
a  37 

a  35 
a  35 
34 
34 
33 
32 
32 
32 
32 


31 
30 

30 
29 
27 
27 
26 
26 
26 
24 

o25 

o25 
23 
23 
23 
23 
22 
22 
22 
20 

o21 
20 
19 
19 
19 
18 
18 
17 
17 
17 

al7 
16 
16 
16 
16 
16 
16 
15 
15 
14 
14 
13 
13 
13 
13 
12 
11 
10 


(4) 
C. 


Deaths 
due  to 
cause 
named  as 
percent- 
age of  all 
deaths. 


(5) 

D. 
Ratio  of 
preventa- 
bility(post- 
ponability), 
i.e.,  ratio  of 
'preventa- 
ble" deaths 
from  cause 
named  to 
all  deaths 
from  cause 
named. 


Per  cent. 
0.4 

.36 

.1 

.5 

.01 
9.9 
7.5 

.2 

.3 

.29 


9.2 
.3 


.6 

.27 

.02 

.6 

.4 

.1 

.02 

.07 

.1 

.5 

.03 

.4 

.05 

.4 

.2 

.03 

.1 

.6 

.6 

.65 

.09 

.9 

.3 

.002 

.8 

.17 

.04 

.4 

.8 

.17 

.27 

.9 

.08 

5.6 
.26 
.5 

1.7 
.03 
.1 

8.1 
.7 
.23 
.4 

4.4 
.2 


(6) 
E=CD. 


Ratio  of 

"preventa 

ble"  deaths 

from  cause 

named  to 

all  deaths 

from  all 

causes. 


Per  cent. 


(7) 
F=BE. 

Years 

added  to 

average 

lifetime  if 

deathswere 

prevented 

in  the  ratio 

of  prevent- 

ability  of 

column  5. 


Per  cent. 
0.34 

.18 
.06 
.28 
.01 
7.42 
2.7 
.16 
.12 


2.76 
.18 

3.15 
.18 
.15 


.2 

.03 

.2 

.1 

.015 

.01 


.4 

,32 

.06 

.54 

.22 

.002 

.2 

.06 

.02 


.07 
.19 


.003 


2.02 
.35 
.07 
.1 

1.54 


.15 

.04 

.34 

.09 

.08 

.02 

.002 

.0006 

.06 

.02 

.05 

.01 

Expectation  "    for  females. 


106 


EEPORT   ON   NATIONAL  VITALITY. 

Possible  prolongation  of  life — Continued. 


(1) 

Cause  of  death. 

(2) 
A. 

Median 
age  of 
dearhs 
from 
causes 

named. 

(3) 
B. 

Expecta- 
tion of 
life  at 
median 
age. 

(4) 
C. 

Deaths 
due  to 
cause 
named  as 
percent- 
age of  all 
deaths. 

(6) 

D. 

Ratio  of 
preventa- 
bility  (post- 
ponability), 
i.e.,  ratio  of 
"  preventa- 
ble" deaths 
from  cause 
named  to 
all  deaths 
from  cause 
named. 

(6) 
E=CD. 

Ratio  of 
"preventa- 
ble" deaths 
from  cause 
named  to 
all  deaths 
from  all 
causes. 

(7) 

F=BE. 

Years 

added  to 

average 

lifetime  if 

deaths  were 

prevented 

in  the  ratio 

of  prevent- 

ability  of 

column  5. 

86.  Softening  of  brain 

Years. 
71 
73 

74 
74 
83 

Years. 
9 
9 
8 
8 
5 

Per  cent. 
0.2 
0.83 
0.2 
0.25 
2 

Per  cent. 

0 
10 
45 
60 

0 

Per  cent. 

Years. 

0.08 
0.09 
0.15 

0.007 

88.  Diseases  of  bladder 

0  007 

89.  Gangrene 

0.01 

90.  Old  age 

All  causes 

38 

100 

42.3 

042.3 

14  06 

KfeUME. 

Diseases  of  infancy  (having  me- 
dian age  1) 

18.5 
4.2 
43 
34.3 

47 
67 
49 
28 

8.8 
2.8 
21.2 
9.5 

4.4 

Diseases  of  childhood  (having  me- 
dian age  2  to  8) 

1.51 

Diseases  of  middle  age  ( having  me- 
dian age  23  to  49) 

6.82 

Diseases  of  late  life  (having  me- 
dian age  52  to  83) 

1.33 

All  causes 

100 

42.3 

42.3 

14.06 

"Although  this  is  the  ratio  of  general  preventability  of  deaths  under  existing  con- 
ditions, the  death  rate,  i.  e.,  deaths  in  relation  to  population,  will  not  in  the  end  be 
affected  in  this  ratio  but  by  only  about  25  per  cent.  The  reason  for  this  paradox  is  that 
deaths  prevented  lead  to  a  larger  population  (See  appendix  to  this  chapter,  section  3). 

Similarly,  if  of  the  ten  lines  three  are  prolonged  each  a  certain 
stated  amount,  or  are  prolonged  that  amount  on  the  average,  the 
average  of  the  whole  ten  will  be  increased  by  three-tenths  of  this 
amount.  Consequently,  if  the  saved  lives  from  typhoid  fever  (No. 
24  in  the  table)  are,  on  an  average,  prolonged  thirty-eight  years,  and 
these  saved  lives  represent  1.7  per  cent  of  all  lives,  the  average  life  will 
be  prolonged  by  1.7  per  cent  of  thirty-eight  years.  This  is  0.65  or 
two-thirds  of  a  year. 

All  the  calculations  are  on  the  assumption  of  expectations  of  life, 
such  that  the  saved  lives  will  die  according  to  the  present  law  of 
mortality.  Consequently,  if  the  table  should  be  corrected  by  sub- 
stituting in  each  case  such  an  expectation  of  life  as  would  conform 
to  the  improved  mortality,  the  result  would  be  an  addition  (2.1 
years) '^  to  the  estimate  of  possible  prolongation,  which  would  there- 
fore become  16.2  years.  The  resume  of  the  table  shows  that  of 
the  14  years  of  possible  prolongation  of  life  4.4  would  be  caused 
by  reducing  infant  deaths  under  or  near  1  year,  1.61  by  reducing 
mortality  from  children's  diseases,  6.82  from  reducing  the  diseases 
of  middle  life,  especially  tuberculosis  and  typhoid,  and  only  1.33 
by  reducing  the  mortality  of  diseases  the  deaths  from  which  usually 
come  after  50  years  of  age. 

"*  Best  estimated  graphically,  as  shown  in  appendix  to  this  chapter. 


EEPORT   ON    NATIONAL.  VITALITY.  107 

The  table  shows  that  seven  of  the  90  causes  of  death  are  responsible 
for  over  half  of  the  shortening  of  life,  namely,  diarrhea  and  enteritis 
^No.  7),  broncho-pneumonia  (No.  10),  meningitis  (No.  13),  typhoid 
(No.  24),  tuberculosis  of  lungs  (No.  31),  violence  (No.  32),  and 
pneumonia  (No.  38).  These  alone  shorten  life  needlessly  by  more 
than  eight  years.  Against  these  seven  causes,  therefore,  our  special 
efforts  should  be  directed.  Pure  milk,  pure  water,  pure  air,  and 
reasonable  protection  from  accident  are  the  chief  means  known  at 
present.  When  the  public  makes  up  its  mind  no  longer  to  endure 
impure  milk,  impure  water,  and  impure  air,  and  unreasonable  dan- 
gers to  life  and  limb,  life  will  lengthen  eight  years,  and  probably  a 
great  deal  more. 

In  the  resume  of  the  table  columns  4,  6,  and  7  are  found  from  the 
original  table  by  simple  addition.  Each  figure  in  the  fifth  column  is 
found  by  dividing  the  figure  in  the  sixth  by  that  in  the  fourth.* 

The  final  figure  in  this  column,  42.3,  is  the  same  as  the  sum  of 
column  6,  and  means  that  according  to  medical  opinion  42.3  per  cent 
of  the  deaths  which  occur  under  present  conditions  are  preventable 
(postponable).  The  death  rate,  however,  will  ultimately  be  reduced, 
not  in  this  proportion,  but  by  about  25  per  cent,^  while  the  average 
duration  of  life  will  be  increased  about  33^  per  cent. 

Section  8. — Diagram  showing  effect  of  prolongation  at  diffei'ent  ages. 

The  whole  process  is  best  seen  by  means  of  a  survivorship  table, 
a  diagram  of  which  will  be  found  facing  page  108. 

We  have  here  four  curves  which  represent  the  survivors  in  suc- 
cessive years  from  a  hypothetical  and  representative  list  of  100,000 
persons  born.  The  two  of  these  curves  which  should  be  noted  are 
the  inner  two,  namely,  those  labeled  "Mass.  1893-97 "  and  "  Pos- 
sible I."  The  former  is  taken,  in  lieu  of  any  better  statistics,  as 
representing  the  existing  law  of  mortality  in  the  United  States.  The 
latter  shows  what  the  law  of  mortality  would  be  if  the  ratios  of  pre- 
ventability  given  in  the  preceding  table  were  put  in  force.  The 
curve  Possible  I  is  constructed  on  the  supposition  that  all  the  deaths 
prevented  or  postponed  subsequently  occur  according  to  the  present 
law  of  mortality ;  that  is,  that  expressed  in  the  curve  Mass.  1893-97. 

The  two  remaining,  or  outer,  curves  are  given  merely  for  com- 
parison. The  lowest,  marked  "  Mass.  1855,"  shows  the  mortality 
which  held  true  in  Massachusetts  in  that  year  according  to  the 
estimates  of  the  actuary,  E.  B.  Elliott."  The  difference  between  this 
curve  and  the  one  above  shows  the  number  of  years  of  life  actually 
saved  to  100,000  persons  subject  to  the  mortality  of  1893-1897  instead 
of  the  mortality  of  1855.  The  upper  curve  (Possible  II)  shows  the 
modification  in  Possible  I  on  the  assumption  that  the  saved  lives, 
instead  of  following  the  present  law  of  mortality   (Massachusetts, 

«Tlie  result  is  in  each  case  a  weighted  average  of  the  individual  ratios  of 
preventability  for  the  individual  causes  of  death. 

^  See  appendix. 

<'  See  Proceedings  of  the  American  Association  for  the  Advancement  of 
Science,  1857,  pp.  61,  69;  also  Sixteenth  Registration  Report,  Massachusetts, 
1857,  p.  204. 


108  EEPORT   ON   NATIONAL  VITALITY. 

1893-1897),  follow  the  law  of  mortality  represented  in  the  curve 
Possible  II  itself." 

This  diagram  shows  at  a  glance  what  improvement  has  been  made 
in  mortality  and  at  what  ages,  and  what  improvement  is  still  pos- 
sible, and  at  what  ages,  according  to  the  preventability  known  to  be 
easily  possible.  We  see  that  the  curve,  Possible  I,  does  not  drop  as 
far  in  the  first  year  of  life  as  the  curve  Mass.  1893-97.  This  is 
because  of  the  great  saving  of  infant  lives  known  to  be  possible.  The 
years  of  life  which  would  be  saved  to  the  100,000  persons  by  the 
new  hygiene  are  represented  by  the  difference  in  area  between  the  new 
curve  AB"C''D  and  the  old  curve  AB'C'D,  from  which  it  was  con- 
structed by  applying  the  ratio  of  preventability.  This  area  can 
easily  be  measured  by  a  planimeter,  and  is  found  to  be  1,280,000, 
which,  divided  by  the  100,000  persons,  means  an  average  addition  of 
12.8  years  to  the  lifetime  of  each  person  born.  This  result  differs 
somewhat  from  the  arithmetical  calculation,  14.06,  given  in  the  pre- 
ceding table.^  If  the  upper  curve  be  used,  which  assumes  that  the 
"  saved  "  lives  die  not  according  to  the  old  but  the  new  mortality, 
the  addition  becomes  not  12.8  but  14.9  years,  as  against  the  16.1 
computed  arithmetically.  We  may  hereafter  refer  to  this  minimum 
estimate  of  possible  increase  of  life  as,  in  round  numbers,  15  years. 
The  lengthening  of  life  would  be  from  45  to  60,  or  one-third. 

The  diagram  also  shows  the  saving  of  life  which  actually  took 
place  between  1855  and  the  period  1893-1897.  The  area  between  the 
curves  for  these  two  periods  shows  that  550,000  years  were  saved  for 
a  supposed  group  of  100.000  persons,  or  5.5  per  person.  The  whole 
area  of  the  new  curve  AB^'C'D  is  5,810,000,  or  68.1  years  per  person, 
which  is  the  new  average  duration  of  life,  as  compared  with  45.3  for 
1893-97  and  39.8  years  for  1855.  We  may  divide  the  diagram  by 
two  vertical  lines  drawn  at  the  ages  17^  and  60  in  order  to  discover 
what  part  of  the  added  life  occurs  between  these  ages — ^that  is,  within 
the  working  period — and  what  parts  fall  on  either  side.  The  addi- 
tion of  12.8  years  to  the  lifetime  of  each  of  100,000  persons,  or 
1,280,000  years  of  life  in  all,  is  divided  into  three  groups,  namely,  the 
years  falling  in  the  period  of  preparation,  200,000;  in  the  working 

<^  The  method  of  constructing  the  curves  Possible  I  and  Possible  II  from  the 
curve  Mass.  1893-97  is  by  means  of  the  ratios  of  preventability  given  in  the 
rgsumg  of  the  preceding  table.     See  appendix. 

*  The  discrepancy,  1.3  years,  is  due  to  the  fact  that  in  constructing  the  table, 
based  on  individual  diseases,  I  was  compelled  to  use  for  the  percentages  of 
deaths  by  ages  (column  4)  the  percentages  obtaining  in  the  calendar  year  1906; 
whereas  the  diagram  is  based  on  the  idea  of  a  stationary  population,  the  dis- 
tribution of  the  deaths  being  represented  by  the  shape  of  the  curve  Mass. 
1893-97.  The  diagrammatic  method  is  therefore  more  correct.  The  abnormal 
age  distribution  in  1906  results  in  making  some  of  the  figures  in  the  last  column 
of  the  table  too  large  and  some  too  small.  In  a  general  way,  the  figures  for 
the  earlier  ages  are  too  large  and  for  the  later  ages  too  small,  although  the 
figures  which  are  most  too  large  are  probably  for  ages  30  to  35.  Consequently 
the  greatest  error  in  excess  is  for  tuberculosis,  which  is  possibly  three-fourths 
of  a  year  too  large.  No  exact  corrections  are  possible,  and  any  systematic 
corrections,  even  inexact,  would  be  very  laborious.  This  would  correspond  to 
the  elaborate  actuarial  calculations  of  Hayward  in  England  and  Glover  in 
the  United  States,  See  Hayward  "  On  the  Construction  of  Life  Tables  and  on 
Their  Application,  etc."  Haydock  and  J.  W.  Glover,  "A  Study  of  Tuberculosis 
In  the  United  States,"  Journal  of  Michigan  State  Medical  Society,  February, 
1909. 


A 


\0  20  30 40  50  60  70  80 90 [00  YeaRS 


90  000 


JO  000 


SURVIVORSHIP  CURVES,  SHOWING  SAFE  MINIMUM   IMPROVEMENT  ATTAINABLE. 


REPORT   ON    NATIONAL  VITALITY. 


period,  680,000;  in  the  period  of  decline,  400,000. 
table  will  show  the  whole  process : 


109 

The  folIowiniT 


Preparatory 

period  (ages 

0-17i). 

Working  pe- 
riod of  life 
(17^0). 

Period  of  de- 
cline (CO  and 
beyond). 

Total. 

Years 
of  life. 

Per 
cent  of 
total. 

Years. 

Per 
cent. 

Years. 

Per 
cent. 

Years. 

Per 
cent. 

Mflss.  1855  

12.6 
13.5 
15.4 

32 
30 
26 

21.9 
25.0 
31.8 

55 
55 
55 

5.3 

6.8 
10.9 

13 
15 
19 

39.8 
45.3 
58.1 

lOO 

Mass.  1893-97 

100 

Possible  I 

100 

These  figures  show  that  in  1855  the  average  person  born  lived  only 
12.6  years  of  the  17^  years  in  the  period  of  preparation  for  life.  In 
1893-97  he  lived  13.5  years.  If  modern  hygiene  were  applied  accord- 
ing to  the  ratios  of  the  assigned  preventability,  the  figure  would  then 
be  15.4  years  actually  lived  out  of  the  17^.  Of  the  working  period  of 
42^  years  (17|^-60,  the  average  man  living  under  the  mortality  of 
1855  had  only  about  half,  or  21.9  years;  under  the  mortality  of 
1893-97  he  had  25.0.  and  under  the  "  Possible  I "  mortality  he  would 
have  31.8  years. 

In  percentage  the  years  in  the  working  period  remain  55  per  cent 
of  the  total  life  in  all  cases.  This  assumes  that  with  the  prolongation 
of  life  the  limits  of  the  working  period  remain  17|  and  60.  Since 
the  prolongation  of  life  carries  with  it  a  postponement  of  the  age  of 
disability,  it  follows  that  the  proportion  of  working  life  would 
actually  increase.'* 

It  will  be  seen  in  comparing  the  curves  on  the  diagram  that  the 
change  wrought  in  the  character  of  the  mortality  curve  by  the  new 
hygiene  simply  continues  the  change  already  in  progress.  The  family 
resemblance  between  all  four  curves  is  striking. 

Section  4. — Fifteen  years  a  safe  minimum  estimate  of  prolongation  possible. 

The  estimate  of  fifteen  years  as  the  possible  prolongation  of  life 
is  merely  a  minimum  estimate.  This  will  be  seen  from  the  following 
important  considerations : 

1.  The  estimate  takes  no  account  of  future  medical  discoveries, 
which  are  now  coming  at  such  a  rate  that  we  have  every  reason  to 
believe  they  will  soon  greatly  increase  the  ratios  of  preventability. 
Cancer,  for  instance,  has  been  put  down  with  zero  as  its  ratio  of  pre- 
ventability, but  the  scientific  world  is  intently  seeking  for  methods 
of  prevention  and  cure.  Likewise  "  old  age  "  has  been  assumed  as 
unpreventable.  Yet  Metchnikoff  maintains  with  reason  that  this 
is  a  malady  which  can  be  postponed. 

2.  The  ratio  of  preventability  of  the  above  diseases  takes  little 
account  of  the  cumulative  influence  of  hygiene.  Certain  diseases  late 
in  life  are  now  taken  to  be  unpreventable  or  only  slightly  prevent- 
able on  the  assumption  that  people  reach  those  ages  in  their  present 
degree  of  more  or  less  imperfect  health.  But  on  the  assumption  that 
personal  hygiene  had  been  practiced  since  birth,  the  vital  resistance,^ 
which  is  always  a  deterrent  of  disease,  would  have  been  strengthened. 

"  See  Dr.  Edward  Jarvis,  "  Political  Economy  of  Health,"  Fifth  Annual  Re- 
port, Mass.  Board  of  Health,  1874,  p.  338,  ff. 


110  EEPOET   ON   ISTATIONAL.  VITALITY. 

Professor  Sedgwick  tells  us  that  evidence  will  be  published  demon- 
strating "  Hazen's  theorem,"  that  every  life  saved  from  typhoid  by 
better  water  supply  means  two  or  three  persons  saved  from  deaths 
from  other  causes.  Our  table  shows  an  estimate  of  at  least  85  per  cent 
as  the  preventability  of  typhoid,  but  the  coincident  preventability  of 
other  diseases  which  this  prevention  of  typhoid  would  bring  about 
finds  no  place  in  the  table.  The  individual  estimates  given  for  these 
other  diseases  take  no  account  of  such  indirect  action.  Similarly, 
as  Metchnikoff  has  emphasized,  venereal  diseases,  though  they  sel- 
dom cause  death,  do  shorten  life,  the  "  terminal  disease  "  being  quite 
different.  The  same  is  true  of  malaria  and  hook-worm  disease,  which 
predispose  to  tuberculosis  and  other  terminal  diseases.  But  in  the 
table  the  ratios  of  preventability  of  tuberculosis  and  other  diseases 
were  constructed  quite  irrespective  of  any  effect  from  reducing 
venereal  diseases,  malaria,  and  other  devitalizing  diseases. 

In  the  matter  of  personal  hygiene  the  cumulative  influence  is  still 
more  indirect,  and  perhaps  still  more  powerful.  It  is  now  often 
remarked  by  insurance  men  that  the  best  risks  are  not  necessarily 
the  best  physiques,  but  may  be  the  valetudinarians  who  practice  per- 
sonal hygiene. 

There  is  a  vicious  circle  of  disease  and  a  beneficent  circle  of  health. 
The  so-called  "  cause  of  death  "  given  in  death  certificates  is  only  the 
terminal  cause.  It  is  often  merely  the  "  last  straw  "  of  a  terrible  load 
gradually  accumulated  through  life. 

Evidently,  to  exploit  the  resources  of  hygiene,  we  need  to  consider 
a  thoroughgoing  change  in  health  ideals  and  a  consequent  revolu- 
tion in  the  conditions  and  habits  of  living.  What  would  then  happen 
to  human  longevity  we  can  only  conjecture.  The  possible  addition 
to  the  life  span  might,  for  aught  we  know,  be  several  times  the  fif- 
teen years  in  the  table. 

3.  The  figures  for  the  possible  prolongation  of  life  take  no  account 
of  the  ultimate  racial  effects  of  the  new  health  ideals.  If  once  a 
nation  becomes  thoroughly  alive  to  the  importance  of  maintaining 
the  stamina  of  its  citizens,  this  will,  as  we  have  seen,  affect  mar- 
riages— by  putting  a  premium  on  health  as  one  of  the  desiderata  in 
a  prospective  husband  or  wife.  The  longevity  of  succeeding  genera- 
tions would  certainly  be  improved — how  much,  it  would  be  useless 
to  guess. 

The  foregoing  considerations,  added  to  the  fact  that  the  estimates 
of  preventability  were  made  conservatively,  will  show  that  the  addi- 
tion of  fifteen  years  is  really  only  a  first  step.  If  clean  milk  will 
prevent  infantile  diarrheal  diseases,  if  clean  water  will  prevent 
deaths  from  typhoid  and  at  the  same  time — according  to  Hazen's 
theorem — prevent  two  or  three  times  as  many  other  deaths,  and  if 
clean  air  will  prevent  tuberculosis,,  then  it  is  evident  that  mere 
cleanliness  in  respect  to  these  necessities  will  suffice  to  lengthen  life 
by  most  if  not  all  of  the  above  estimate.  Fifteen  years  is  merely  the 
"  ore  in  sight."  If  we  will  work  for  it,  we  may  get  an  even  richer 
prize. 

Within  the  past  few  years  the  knowledge  of  the  causes  of  disease  has  become 
so  far  advanced  that  it  is  a  matter  of  practical  certainty  that  by  the  unstinted 
application  of  known  methods  of  investigation  and  consequent  controlling  action, 
all  epidemic  disease  could  be  abolished  within  a  period  so  short  as  fifty  years." 

«E.  Ray  Lankester,  "The  Kingdom  of  Man,"  New  York  (Holt),  1907,  p.  36. 


KEPORT   ON    NATIONAL   VITALITY.  Ill 

Section  5. — 'Need  of  lengthening  human  life. 

If  Metchnikoff's  noble  dream  should  be  some  day  realized,  the 
lengthening  of  human  life  would  at  once  decrease  the  burden  on  the 
productive  period.  That  period  tends  to  remain  55  per  cent  of  the 
total  years  lived,  on  the  assumption  that  the  working  period  remains 
17^  to  60,  but  the  upper  limit  tends  to  shift  forward.  In  this  way, 
both  the  absolute  and  relative  length  of  the  working  period  would 
be  increased. 

The  further  off  the  burden  of  old  age  is  shifted,  the  easier  it  is 
for  society  or  the  individual  to  accumulate  the  wealth  to  provide  for 
it.  At  present  the  burden  of  helpless  old  age  is  extremely  serious, 
as  those  countries  are  beginning  to  realize  which,  like  Denmark, 
Belgium,  Germany,  France,  and  recently  England,  have  enacted  laws 
to  provide  old-age  pensions. 

As  life  becomes  more  complex  it  requires  a  longer  period  of  prepa- 
ration. Preparation  is  education,  and  requires  time.  As  the  stock 
of  knowledge  increases,  the  period  for  acquiring  it,  or  rather  only 
enough  of  it  to  enable  one  to  earn  a  livelihood,  is  constantly  tending 
to  increase.  The  age  of  leaving  school  and  college  is  presumably 
growing  greater. 

It  would  be  very  much  in  keeping  with  the  fitness  of  things  if  in 
this  century  biological  science  practically  applied  should  shift  the 
limit  of  the  further  end  of  the  working  period,  the  limit  which  we 
have  assumed  to  be  60,  to  a  later  period  of  life.  Human  life  would 
then  be  on  a  larger  scale  throughout.  It  would  provide  time  for  a 
longer  and  more  thorough  preparation  and  at  the  same  time  provide 
sufficient  years  of  working  life  to  repay  this  investment. 

As  Metchnikoff<^  well  points  out,  one  result  of  lengthening  life 
will  be  a  greater  utilization  of  accumulated  experience.  We  shall 
have  less  immaturity  of  judgment.  The  principle  which  leads  to 
the  choice  for  members  of  the  judiciary  of  men  of  ripe  years  and 
knowledge  will  apply  to  every  field  of  human  activity,  even  those  fields 
which  are  now  preempted  by  young  men  because  of  the  necessity 
of  utilizing  their  vitality.  It  will  lead  to  a  sane  and  yet  a  vigorous 
conservatism.  It  will  give  to  society  a  body  of  old  yet  hale  men  of 
experience,  whose  influence  and  worth  can  not  be  measured.  As 
Metchnikoff  has  said : 

Old  age,  at  present  practically  a  useless  burden  on  the  community,  will  become 
a  period  of  work  valuable  to  the  community.  As  the  old  man  will  no  longer 
be  subject  to  loss  of  memory  or  to  intellectual  weakness,  he  will  be  able  to 
apply  his  great  experience  to  the  most  complicated  and  the  most  delicate  parts 
of  the  social  life.* 

We  may  predict  that  when  science  occupies  the  preponderating  place  in  human 
society  that  it  ought  to  have,  and  when  knowledge  of  hygiene  is  more  advanced, 
human  life  will  become  much  longer  and  the  part  of  old  people  will  become  much 
more  important  than  it  is  to-day.'' 

Section  6. — The  normal  lifetime. 

Wliat  is  the  normal  hum.an  lifetime  ?  ^  Many  estimates  have  been 
made,  based  on  all  sorts  of  reasoning,  the  figures  extending  from  75 

«  Prolongation  of  Life,  p.  329. 

*  Nature  of  Man,  p.  295. 

°  Metchnikoff :  "  Prolongation  of  Life,"  pp.  226-227. 

^  On  the  topic  of  human  longevity,  see  MetchnikofC :  '"  The  Prolongation  of 
Life,"  Pt.  II,  Chaps.  I,  II.  Shaler  :  "  The  Individual,"  New  York  (Appleton),1901, 
Chap.  III.     Lankester :  "  Comparative  Longevity,"  London,  1870,  pp.  88-119. 


112  REPORT   ON    NATIONAL  VITALITY. 

to  200  years.  Flourens's  law,  of  doubtful  value,  that  a  mammal  lives 
five  times  the  length  of  its  growing  period,  can  not  be  applied  gener- 
ally. It  is  true,  the  horse  full  grown  at  5  may  live  25  years;  sheep 
adult  at  less  than  3  years  may  live  12 ;  while  elephants,  which  have  an 
unusually  tardy  development,  are  reputed  to  have  a  lifetime  of  2 
centuries. 

Haller,  a  distinguished  Swiss  physiologist  of  the  eighteenth  century,  thought 
that  man  ought  to  live  to  200  years;  Buffon  was  of  the  opinion  that  when  a 
man  did  not  die  from  some  accident  or  disease  he  would  reach  90  or  100  years.** 

In  man  the  growth  period  is  normally  continued  to  some  time  after  the 
twentieth  year ;  its  exact  limit  has  not  been  ascertained,  but  from  the  statistics 
gathered  by  the  Sanitary  Commission  during  the  civil  war  it  seems  most  likely 
that  it  is  not  usually  completed  until  after  the  thirtieth  year.* 

One  method  which  has  been  suggested  to  ascertain  the  natural 
length  of  life  is  to  suppose  all  diseases  to  be  completely  elirninated 
and  those  who  now  die  of  them  to  die  of  old  age.  The  median  age 
for  death  from  old  age  is  83.  Metchnikoff,  however,  shows  the  error 
of  assuming  present  old  age  to  be  normal.  We  may  conclude  that 
the  normal  life  exceeds  83. 

There  must  needs  be,  of  course,  a  limit  to  the  possible  prolongation 
of  life.  We  find  in  recent  times  few  authenticated  cases  of  persons 
who  have  lived  for  a  hundred  years.  As  Young,  former  president  of 
the  British  Actuarial  Society,  has  shown  in  his  interesting  book  '^  on 
centenarians,  most  cases  of  supposed  centenarians  are  either  cases  of 
conscious  or  unconscious  exaggeration  or  of  error  in  records.  For 
instance,  the  Countess  of  Desmond  is  said  to  have  lived  130  years, 
owing  to  the  confusion  of  two  persons  of  the  same  name,  one  of  whom 
lived  to  be  100  years  old,  while  the  other,  her  mother,  died  at  30,  and 
their  lives  were  combined  in  subsequent  records.  There  are,  however, 
some  authenticated  cases.  Thus,  the  Norwegian  Drakenberg  was 
bom  in  1626  and  lived  until  1772,  aged  146.  "  He  was  married  when 
111  years  old,  and  as  a  widower  of  130  proposed  to  marry  again, 
although  without  success."*^ 

At  Portland,  Or  eg.,  Mrs.  Mary  L.  Wood  died  recently  at  the  age 
of  120  years  and  under  circumstances  which  permitted  the  authenti- 
cation of  her  case  by  the  Oregon  Historical  Society.  From  these  and 
from  other  cases  which  might  be  mentioned,  we  may  conclude  that 
if  to-day,  notwithstanding  all  existing  chances  of  death,  it  is  possible 
for  some  persons  to  live  beyond  120,  the  chances  in  the  future  for  a 
larger  proportion  of  such  persons  will  be  materially  improved. 
Whether  this  proportion  could  ever  become  the  major  part  we  have 
as  yet  no  means  of  knowing.  What  is  needed  is  study,  and  Metchni- 
koff  is  right  in  believing  that  the  study  is  well  worth  while  from 
every  point  of  view. 

Appendix  to  Chapter  XI. — Method  of  computing  possible  prolongation  of  life. 
Section  1. — "  Expectations  "  at  median  ages  as  short  cut  to  average  expectations. 
The  table  given  in  Chapter  XI  is  briefly  described  in  the  chapter  itself.     The 
following  additional  explanations  are  made  in  regard  to  the  statistical  method 
employed : 

°  Metchnikoff,  "  Prolongation  of  Life,"  p.  84. 
6  Shaler,  loc.  cit,  p.  61. 

CT.  E.  Young:  "Centenarians,"  London  (C.  &  E.  Layton),  1899. 
<*  See  article  by  Harald  Westergaard,   (British)   Economic  Journal,  Vol.  IX, 
1899,  p.  315. 


REPORT   ON    NATIONAL  VITALITY.  113 

The  third  column,  giving  the  expectation  of  life  which  is  lost  or  cut  off  by 
each  particular  cause  of  death,  is  estimated  roughly  by  taking  the  expectation 
of  life  pertaining  to  the  median  age  reached  by  those  who  die  from  the  cause 
named.  This  expectation  of  life  is  taken  from  the  Massachusetts  Life  Tables, 
1893-1897.« 

The  method  of  using  the  median  age  is  suflSciently  exact  in  view  of  the  inexact, 
or  rather,  safe,  minimum  estimates  of  preventability  given  in  column  five.  A  per- 
fectly correct  method  would  be  much  more  laborious.  Hayward's  monograph 
on  the  effect  on  the  duration  of  life  of  eliminating  only  one  disease  (tubercu- 
losis) requires  190  pages  of  calculation.  The  true  method  consists  in  averaging 
arithmetically  and  weighting  these  averages  according  to  the  number  dying  at 
the  various  ages.  Specimen  computations  show  that  the  error  involved  by  the 
short  cut  is  not  great. 

Thus,  for  tuberculosis  it  is  found  that  the  average  expectation  of  life  lest 
by  consumptives  dying  in  1906  was  32  years,  whereas  the  expectation  of  life 
at  the  median  age  was  33  years.  The  former  figure  is  a  hundredfold  more  diffi- 
cult to  compute  than  the  latter.  Even  the  former  is  not  strictly  correct,  since 
it  applies  lo  the  deaths  by  ages  as  distributed  in  1906,  and  not  as  distributed  in 
a  "  stationary  "  population. 

Section  2. — Basis  of  estimates  of  preventability. 

The  estimates  of  preventability  given  in  column  5  need  special  explanation. 
In  a  few  cases,  these  estimates  are  based  on  statistical  experience.* 

The  great  majority  of  them  are  based  on  clinical  experience  merely,  without 
any  exact  statistics.  They  are  thus  in  the  nature  of  expert  guesses.  The 
experts  in  all  cases  are  physicians.  I  have  not  entered  any  estimate  of  my 
own,  unless  item  No.  36  might  be  so  designated.  This  item  is  the  residuum  of 
deaths  from  unknown  causes,  or  ill-defined  causes,  and  is  made  up  to  a  large 
extent  of  cases  not  properly  reported  in  the  death  certificates.  Inasmuch  as  the 
average  preventability  for  all  other  causes  in  the  table  is  over  42  per  cent,  it 
seemed  safe  to  assign  to  deaths  fi'om  these  unknown  causes  a  ratio  of  pre- 
ventability of  30  per  cent.  But  even  if  the  preventability  were  entered  as  0, 
the  effect  in  reducing  the  result  would  be  less  than  a  year. 

Those  who  gave  to  the  construction  of  these  estimates  the  benefit  of  their 
experience,  observations,  and  reading  were  especially  asked  above  all  to  be  con- 
servative.    In  order  to  avoid  any  possibility  of  exaggeration  of  their  estimates 

OS.  W.  Abbott,  M.  D. :  "The  vital  statistics  of  Massachusetts  for  1897,  from 
the  thirtieth  annual  report  of  the  state  board  of  health  of  Massachusetts." 
The  expectation  is  taken  as  the  average  of  the  expectations  for  males  and 
females. 

*  In  addition  to  the  data  in  regard  to  special  diseases  discussed  in  the  text, 
other  pertinent  material  has  been  taken  into  account  by  those  who  made  the 
estimates  presented  in  the  table.  For  instance,  fropi  smallpox  in  London  in 
1901-2  the  mortality  was  34.6  per  cent  among  the  unvaccinated,  20.9  per  cent 
among  those  vaccinated  after  the  disease  was  apparent,  and  10.3  per  cent  where 
there  was  protective  vaccination.  In  Gloucester  in  1895-96  the  mortality  among 
the  unvaccinated  was  40.8  per  cent  and  among  the  vaccinated  9.8  per  cent.  For 
children  under  1  year  the  unvaccinated  had  a  mortality  of  72  per  cent,  while 
the  vaccinated  were  not  attacked.  From  cerebro-spinal  meningitis  the  average 
mortality  was  70  per  cent  (Holt)  ;  the  mortality  under  serum  treatment  was  25 
per  cent  (Flexner  and  Jobling).  For  typhoid  fever,  Koch  and  his  assistants 
stamped  out  the  disease  in  Trier  by  isolation  of  the  infected  persons  and  dis- 
infection. (Osier,  The  Practice  of  Medicine,  sixth  edition.)  This  would  prob- 
ably be  impracticable  to  such  an  extent  in  a  city  on  account  of  the  great  expense 
involved  and  the  diflBculty  of  detecting  the  bacillus  carriers.  Other  figures  for 
typhoid  fever  are  given  in  the  text.  For  diphtheria  in  New  York  City  in  1889- 
1891  we  find  the  mortality  was  37.3  per  cent,  while  in  1902-1904  the  mortality 
was  10.8  per  cent.  The  board  of  health  began  to  use  antitoxin  in  1895.  These 
facts  were  furnished  by  Professor  Blumer.  Many  data  on  preventability  are 
given  by  John  C.  McVail  in  The  Prevention  of  Infectious  Diseases,  New  York 
(Macmillan),  1907.  See  especially  pages  16-19.  Doctor  Stiles,  of  the  Public 
Health  and  Marine-Hospital  Service,  is  soon  to  publish  figures  showing  the 
absolute  preventability  of  hook-worm  disease,  a  malady  prevalent  in  the  South, 
but  not  entering  into  the  census  tables.  These  tables  do  not  cover  the  Southern 
States. 


114  REPOET   ON   NATIONAL  VITALITY. 

in  the  table  their  average  was  taken,  and  then  the  estimate,  as  entered  in  the 
table,  was  taken  either  as  that  average  or  below  it.  In  no  case  was  the  estimate 
entered  as  above  the  average  given.  When,  as  was  true  in  a  large  proportion 
of  cases,  the  different  estimates  agreed  fairly  well,  the  average  was  employed, 
or  rather  the  nearest  figure  ending  in  0,  or  5  next  below  the  average.  If  the 
individual  estimates  diverged  widely,  an  estimate  was  used  below  the  average, 
favoring  the  conservative  estimators  rather  than  the  optimistic.  Also  in  cases 
where  only  a  few  estimates  were  obtainable,  the  estimate  as  entered  was  put 
below  the  average  of  those  given. 

In  estimating  the  percentage  of  preventability  for  all  the  ninety  causes  of 
death,  IS  estimators  contributed.  The  number  of  estimates  of  preventability 
for  each  cause  averaged  nearly  eight  for  each  cause  of  death.  It  will  be  seen, 
therefore,  that  the  table  represents  in  a  conservative  way  medical  opinion  as  to 
the  preventability  of  disease.  The  physicians  who  contributed  these  estimates 
are :  Dr.  Joseph  M.  Flint,  professor  of  surgery,  Yale  Medical  School ;  Dr.  George 
Blumer,  professor  of  the  theory  and  practice  of  Medicine,  Yale  Medical  School; 
Dr.  H.  L.  Swain,  clinical  professor,  Yale  Medical  School;  Dr.  Oliver  T.  Osborne, 
professor  of  therapeutics,  Yale  Medical  School ;  Dr.  J.  H.  Townsend,  secretary 
of  Connecticut  state  board  of  health ;  Dr.  F.  W.  Wright,  health  officer  of  New 
Haven ;  Dr.  Norman  E.  Ditman,  of  Columbia  University ;  Dr.  Cressy  L.  Wilbur, 
Chief  of  Division  of  Vital  Statistics,  Bureau  of  the  Census ;  Dr.  L.  O.  Howard, 
Chief  of  Bureau  of  Entomology,  Department  of  Agriculture;  Dr.  William  G, 
Woodward,  chief  health  officer  of  District  of  Columbia ;  Dr.  Charles  V.  Chapin, 
city  health  officer.  Providence,  E.  I. ;  Dr.  Henry  B.  Baker,  ex-secretary  Michigan 
state  board  of  health,  ex-president  American  Public  Health  Association;  Dr. 
J.  H.  Kellogg,  superintendent  of  the  Battle  Creek  Sanitarium ;  Dr.  Charles  H. 
Castle,  of  Cincinnati,  Ohio;  Dr.  Harry  M.  Steele,-  of  New  Haven,  Conn.; 
Dr.  L.  Emmett  Holt,  of  New  York ;  Dr.  Edwin  O.  Jordan,  of  the  Memorial  Insti- 
tute for  Infectious  Diseases,  Chicago,  111. ;  Dr.  Prince  A.  Morrow,  president  of 
the  American  Society  for  Sanitary  and  Moral  Prophylaxis. 

Section  3. — Meaning  of  "  preventable. " 

The  meaning  of  the  word  "  preventable  "  requires  some  explanation. 

1.  It  is  to  be  noted  that  column  5  gives  the  ratio  of  preventability  for  mor- 
tality and  not  for  morbidity.  It  means  ratio  of  preventable  deaths  to  all  deaths, 
not  to  all  cases  of  illness. 

2.  Since  the  word  "  preventable  "  implies  the  hypothesis  of  different  conditions 
from  those  which  actually  exist,  it  is  necessary  to  specify  what  hypothetical 
conditions  shall  be  implied  in  the  term.  Doubtless  tuberculosis  would  be  over 
99  per  cent  preventable  if  we  should  conceive  as  our  hypothetical  conditions  that 
every  individual  could  live  on  the  prairies  of  the  West,  out  of  doors,  be  provided 
with  the  best  of  food,  most  congenial  of  tasks,  and  free  from  overwork  and 
worry.  Needless  to  say,  the  figures  in  the  table  do  not  imply  such  Utopian  con- 
ditions, nor  do  they  imply  new  medical  discoveries.  One  hundred  per  cent  of 
every  disease  might  be  preventable  if  we  conceived  as  our  hypothesis  that  the 
means  of  prevention  are  known  and  applied.  The  hypothetical  condition 
selected  for  the  meaning  of  the  term  "  preventable  "  is  contained  in  the  following 
definition :  A  "  ratio  of  preventahility "  is  the  fraction  of  all  deaths  which 
would  6e  avoided  if  knowledge  now  existing  among  well-informed  men  in  the 
medical  profession  were  actually  applied  in  a  reasonaUe  way  and  to  a  reason- 
atle  extent.  The  term  "  reasonable  "  is  of  course  elastic,  and  will  be  somewhat 
differently  interpreted  by  different  persons,  but,  as  in  law,  where  "  reasonable 
care"  is  often  used  as  a  proviso,  it  is  impossible  to  make  any  more  specific 
condition. 

3.  Considerable  confusion  exists  in  the  minds  of  many  people  in  regard  to  the 
number  of  deaths  which  might  be  prevented,  or,  as  it  is  popularly  expressed, 
the  number  of  lives  which  might  be  saved.  Since  death  is  ultimately  inevitable 
for  all,  no  life  can  be  saved  except  temporarily.  It  will  serve  to  avoid  confusion 
if  "  preventable "  is  explained  as  "  postponable."  The  question  arises  when 
deaths  are  postponed.  How  long  are  they  postponed?  The  answer  is.  They  are 
supposed  to  occur  according  to  existing  rates  of  mox'tality.  Thus,  those  saved 
from  croup  (No.  12)  at  age  2  will  later  die  as  do  others  who  are  living  at  age  2, 
and  will  therefore  have  the  expectation  of  life  (54  years)  pertaining  to  that  age. 

4.  The  above  explanation  will  serve  to  meet  an  objection  which  otherwise 
would  immediately  occur  to  the  reader.  If  diseases  of  early  life  are  prevented, 
the  result  will  necessarily  be  an  increase  of  the  diseases  in  later  life.    For 


BEPORT   ON    NATIONAL  VITALITY.  115 

instance,  if  all  the  causes  of  death  could  be  abolished  except  old  age,  there 
would  be  a  great  increase  in  the  number  of  deaths  from  old  age,  which,  instead 
of  constituting  the  2  per  cent  of  all  deaths,  which  it  does  at  present,  would  con- 
stitute 100  per  cent. 

But  the  fact  that  all  lives  saved  will  add  to  the  later  mortality  is  fully,  and 
more  than  fully,  taken  into  account  in  our  calculations.  When  we  assume  that 
certain  lives  now  lost  at  a  given  age  might  be  saved,  we  also  assume  that  they 
would  not  be  saved  again  (even  from  the  same  disease),  but  would  die  off 
according  to  the  old  rates  of  mortality  at  successive  ages.  Their  new  lease  of 
life  would  simply  be  the  old  expectation  of  life.  As  a  matter  of  fact,  lives  now 
lost  could  probably  be  saved,  not  only  once,  but  several  times. 

We  may  here  explain  the  paradox  mentioned  in  the  text — namely,  that  a 
preventability  of  42.3  per  cent  of  deaths  under  present  conditions  does  not  imply 
that  the  death  rate  would  ultimately  be  reduced  42.3  per  cent. 

The  death  rate  would  ultimately  depend  on  conditions  of  the  distribution 
of  ages  and  diseases  entirely  different  from  those  now  prevailing.  This  will 
be  clear  if  we  think  what  would  happen  if  the  preventability  expressed  in  the 
table  could  be  immediately  applied.  During  the  ensuing  year  it  would  be  found 
that  about  42  per  cent  of  present  deaths  would  not  occur.  A  consequence  of 
this,  however,  would  be  that  the  persons  whose  lives  were  prolonged  would  die 
at  a  later  period,  since  no  death  is  absolutely  prevented,  but  only  postponed. 
Even  if  100  per  cent  of  all  deaths  were  prevented  (postponed),  but  the  post- 
ponement were  for  a  very  short  time,  the  effect  in  reducing  the  death  rate 
would  be  extremely  small.  On  the  other  hand,  if  only  1  per  cent  of  the  prevent- 
able deaths  were  postponed  for  a  sufficiently  long  time,  the  ultimate  effect  would 
be  to  reduce  the  death  rate  much  more  than  1  per  cent.  After  the  deaths 
which  had  been  postponed  had  reentered,  a  new  equilibrium  would  be  estab- 
lished. Under  these  new  conditions  the  ratio  of  the  deaths  to  the  population 
would  not  be  42.3  per  cent  lower  than  at  present,  but  only  about  25  per  cent. 
At  present  the  average  duration  of  life,  taken  from  the  Massachusetts  table 
for  1893-1897,  is  about  45  years.  The  ratio  of  preventability  in  the  above  table 
would  increase  this  life  by  about  fifteen  years,  making  it  60  years.  The  ratio 
of  45  to  60,  showing  the  increase  in  the  life  span,  will  be  the  inverse  of  the 
ratio  60  to  45  in  a  "  stationary  "  population,  which  would  show  the  resulting 
reduction  in  the  death  rate.  This  is  a  reduction  of  25  per  cent.  Thus  the  pre- 
ventability of  42.3  per  cent  of  deaths  under  present  conditions  and  in  the  man- 
ner indicated  in  the  table  involves  a  lengthening  of  life  of  33^  per  cent  and  a 
reduction  of  the  death  rate,  after  readjustment  of  deaths  by  ages,  of  about  25 
per  cent. 

Section  4. — Error  from  abnormal  age  distribution  of  deaths  in  1906. 

The  table  as  given  is  constructed  for  deaths  occurring  in  the  calendar  year 
1906.  Its  interpretation,  however,  is  to  be  made  on  the  basis  of  a  survivorship 
table.  In  a  stationary  population  the  age  distribution  of  deaths  in  any  year 
would  be  the  same  as  in  a  survivorship  table;  but  since  the  United  States  has 
not  a  stationary  population,  this  identity  holds  only  approximately. 

The  discrepancy  accounts  for  the  difference  of  one  and  three-tenths  years  in 
the  prolongation  of  life,  as  calculated  in  the  table  and  by  means  of  the  dia- 
gram. The  latter  is  the  more  correct,  as  it  is  based  on  a  survivorship  table,^ 
or — what  amounts  to  the  same  thing — on  such  mortality  as  would  exist  in  a 
stationary  population.  The  only  way  in  which  this  diagram  can  be  vitiated 
by  the  slightly  abnormal  age  distribution  of  deaths  in  the  year  1906  is  as  this 
abnormal  distribution  affects  the  average  ratios  of  preventability  used  in  con- 
structing the  diagram.  These  ratios  are  based  on  column  (5)  of  the  resume 
of  the  table.  The  four  figures  from  the  table  are  adjusted  by  graphic  interpola- 
tion in  the  usual  way,  so  as  to  form  a  continuously  vai'ying  series  of  figures  for 
successive  years  of  life.  These  ratios  are  in  each  case  an  average  of  the  indi- 
vidual ratios  for  particular  diseases,  contained  in  the  same  column  (5)  of  the 
larger  table.  The  "  weights  "  are  slightly  vitiated  by  the  fact  that  the  age  dis- 
tribution of  deaths  in  1906  is  not  the  normal  distribution  of  a  stationary  popula- 
tion. It  is  only  as  the  "  weighting  "  is  thus  affected  that  the  diagram  can  be 
vitiated  through  our  being  forced  to  use  the  figures  for  1906  instead  of  those 
for  an  ideal  stationary  population,  since  such  figures  are  unobtainable.  The 
error  from  this  source  is  infinitesimal,  and  we  may  depend  on  the  results  of  the 
diagram,  12.8  to  14.9  years,  as  practically  free  from  any  appreciable  error  due 
to  the  use  of  short-cut  methods. 


116  KEPOET   ON   NATIONAL  VITALITY. 

Section  5. — Ratios  of  preventaMlity  hy  ages  derived  from,  ratios  "by  diseases. 

In  regard  to  the  resume  containing  the  average  ratios  of  preventability  hold- 
ing true  during  different  ages,  it  will  be  observed  that  they  are  obtained  indi- 
rectly, by  calculating  from  the  individual  ratios  of  preventability  for  different 
diseases  given  in  the  table  itself.  Although  these  diseases  are  not  absolutely 
limited  to  the  times  within  which  their  median  falls,  there  is  a  fairly  distinct 
line  of  demarcation  between  the  groups,  especially  between  children's  diseases 
and  those  of  middle  life.  The  table  shows  no  disease  with  a  median  age  of 
incidence  between  8  and  23  years,  and  the  census  table  of  deaths  for  1906  shows 
that  a  very  small  percentage  of  the  total  deaths  occur  between  ages  10  and  20. 
Even  if  the  diseases  considered  for  the  four  epochs  of  life  given  in  the  resume 
did  extend  somewhat  into  the  regions  of  the  adjacent  epochs,  the  effect  would 
not  change  the  result  appreciably  and  would  be  as  likely  to  change  it  in  one 
direction  as  the  other.  The  reason  is  that  the  items  of  the  column  in  the 
resume  for  "  ratio  of  preventability  "  are  obtained  by  dividing  the  figures  in 
column  6  by  those  in  column  4,  each  of  these  two  being  found  by  adding  the 
individual  figures  in  the  table  for  each  age  group  concerned.  The  extension 
of  diseases  of  an  age  group  outside  of  that  group  will  apply  equally  to  both 
terms  of  the  ratio,  those  in  the  fourth  and  sixth  columns,  and  will  not  substan- 
tially affect  the  quotient  in  the  fifth  column. 

Section  G. — Allowance  for  weakness  of  prolonged  lives. 

The  use  in  column  2  of  the  expectations  of  life  derived  from  the  Massachu- 
setts 1893-1897  life  table  is  equivalent  to  the  assumption  that  if  preventable 
deaths  were  prevented  the  lives  thus  saved  would  proceed  to  die  off  according 
to  the  mortality  of  Massachusetts,  1893-1897.  This  assumes  that  since  1893-1897 
there  has  been  no  improvement  in  the  expectation  of  life,  and  that  the  saved 
lives  will  not  share  in  the  improvement  which  the  table  itself  shows  forth.  The 
reason  that  a  later  life  table  than  for  1893-1897  was  not  used  is  that  no  later 
life  table  is  available.  If  it  were,  it  would  show  larger  figures  in  column  2, 
and  consequently  a  larger  total  result  for  the  possible  prolongation  of  life  than 
fourteen  years. 

The  reason  the  "  expectation  "  in  column  3  does  not  take  account  of  the  effect 
of  the  improvement  in  mortality  resulting  from  the  table  is  that  this  improve- 
ment can  not  be  calculated  until  column  3  is  filled,  and  we  prefer  to  use  as  a  first 
approximation  a  conservative  figure  in  column  3,  rather  than  to  guess  at  more 
likely  figures.  The  conservative  assumption  used  seems  also  advisable,  because 
of  the  fact  that  in  the  42.3  per  cent  of  persons  in  the  life  table  who  would  be 
saved  from  death  and  gi^en  a  new  lease  of  life  there  would  be  suffered  a  greater 
mortality  than  that  of  the  average  persons  that  now  pass  that  age  in  safety, 
for — on  the  principle  of  the  survival  of  the  fittest — it  is  intrinsically  probable 
that  those  who  now  die  at  any  age  are  weaker  than  those  who  do  not. 

How  much  allowance  should  be  made  for  this  factor  of  differential  mortality 
it  is  impossible  to  say  with  certainty.  But  in  another  paper  ^  I  have  dealt  with 
the  same  question  applied  to  tuberculosis.  Taking  the  figures  of  Dr.  Lawrason 
Brown,  giving  the  mortality  experience  among  the  apparently  cured  cases  of 
tuberculosis  discharged  from  the  Adirondack  Cottage  Sanitarium,  and  making 
certain  allowances,  it  seems  that  if  tuberculosis  were  prevented  its  present  vic- 
tims would  have  more  than  three-fourths  of  the  expectation  of  life  belonging  to 
•others.  Let  us  assume  that  this  ratio  is  equally  conservative  as  applied  to  all 
other  cases  of  prolongable  life.  Now,  it  so  happens  that  the  expectation  of  life 
at  birth  in  the  Massachusetts  life  table  of  1893-1897  is  almost  exactly  three- 
fourths  of  the  expectation  which  our  table  and  diagram  shows  would  be  possible 
if  prevention  were  properly  practiced.  This  would  give  45  years  as  the  expecta- 
tion of  life  at  birth  for  the  saved  lives,  61  for  other  lives,  and  59  for  all  lives. 
Surely  this  seems  sufficient  allowance  for  the  existence  of  any  possible  inferior- 
ity among  the  lives  which  would  be  saved. 

Section  7. — Diagram  "PossiMe  I/'  making  this  allowance,  compared  with  "Possible  II," 

omitting  it. 

If  no  allowance  for  inferiority  among  saved  lives  were  necessary,  the  results 
of  the  calculation  given  in  the  table  would  be  only  a  first  approximation  and 

"  "The  cost  of  tuberculosis  in  the  United  States  and  its  reduction,"  read  before 
the  International  Congress  on  Tuberculosis,  1908. 


REPORT   ON    NATIONAL  VITALITY.  117 

would  need  to  be  followed  by  successive  and  closer  approximations.    We  can  get 
mucli  quicker  results  by  means  of  the  diagram  and  a  planimeter. 

If  we  apply  the  ratios  of  preventability  for  these  four  groups,  we  are  able  to 
construct  the  new  survivorship  table  on  the  basis  of  Mr.  Abbott's  for  1893-1897. 
All  that  is  necessary  is  to  begin  the  now  survivorship  table  at  the  same  point 
that  the  old  begins,  and  continue  from  that  point  and  every  other  point  through- 
out its  course  by  the  following  procedure:  Through  the  point  draw  a  line  down- 
ward and  to  the  right  for  one  year,  at  the  same  percentage  slope  as  Abbott's 
table  shows  for  that  year.  This  line  indicates  what  survivors  there  would  be  if 
their  mortality  were  not  affected  at  all  by  the  ratio  of  preventability.  The 
deaths  during  that  year  would  be  represented  by  the  drop  of  the  curve  within 
the  year.  Next,  taking  the  proper  fraction  of  this  drop,  as  indicated  by  the 
ratio  of  preventability,  we  pass  vertically  upward  this  amount  from  the  end  of 
the  line,  and  from  the  new  point  so  obtained  proceed  in  like  manner  for  each 
subsequent  year.  The  result  is  a  series  of  teeth  the  upper  points  of  which  are 
points  on  the  required  curve.  Joining  these  points,  we  obtain  the  curve.  This 
process  explains  the  theory.  This  gives  the  table  called  "  Possible  I,"  and  takes 
full  account  of  the  fact  that  the  ratios  of  preventability  continue  to  apply  to 
saved  life  as  much  as  to  other  life.  The  table  "  Possible  I  "  represents  the  sur- 
vivorship table,  under  the  assumption  that  the  lives  saved  once  are  given  no 
further  advantages,  but  follow  thereafter  the  old  law  of  mortality,  that  for 
1893-1897. 

Section  8. — Reciprocal  relation  Vetween  longevity  and  mortality  shown  iy  diagram. 

We  may  take  this  opportunity  to  explain,  for  the  benefit  of  the  general  reader, 
the  reciprocal  relations  existing  between  the  death  rate  in  a  stationary  popula- 
tion and  the  average  duration  of  life.  Consider  the  diagram  "  Massachusetts, 
1893-1897."  It  shows  the  life  history  of  100,000  persons  born.  Let  us  suppose 
a  community  unaffected  by  emigration  or  immigration,  and  in  which  there  are 
100,000  births  each  year.  Let  us  suppose,  further,  that  the  100,000  persons  born 
each  year  die  afterwards  according  to  the  law  of  mortality  represented  by  the 
curve  "  Massachusetts,  1893-1897."  Evidently  in  such  a  community  there  will 
not  only  be  100,000  births,  but  there  will  be  100,000  deaths  each  year,  and  the 
population  will  be  stationary.  It  will  also  be  true  that  the  same  diagram  can 
be  taken  to  represent  the  age  distribution  of  this  stationary  population.  Thus, 
those  living  at  age  10  will  be  the  survivors  of  the  100,000  born  ten  years  ago, 
and  the  number  of  such  survivors  is  the  ordinate  of  the  curve  at  10  years. 
Thus,  every  ordinate  of  the  curve  represents  not  only  the  survivors  to  a  certain 
age  out  of  100,000  births,  but  also  represents  the  number  in  the  population  at 
that  age.  The  area  of  the  curve  therefore  represents  total  population  (when 
regarded  as  made  up  of  vertical  sections).  It  likewise  represents  the  total 
number  of  years  lived  by  100,000  persons  (when  regarded  as  made  up  of  hori- 
zontal sections).  Now,  the  death  rate  is  the  ratio  of  deaths  to  population — i.  e., 
the  ratio  of  100,000  to  the  area  of  the  curve.  The  average  duration  of  life  is 
the  total  years  lived  by  100,000  persons  divided  by  100,000— that  is,  it  is  the 
area  of  the  curve  divided  by  100,000.    These  are  clearly  reciprocals. 

Chapter  XII. — The  money  value  of  increased  vitality. 
Section  1. — Money  appraisal  of  preventable  wastes. 

Estimates  of  the  money  value  of  preventable  wastes  depend  on  the 
valuation  of  human  life,  of  which  several  appraisals  have  been 
attempted. 

Prof.  J.  S.  Nicholson  estimated  that  in  Great  Britain  human  labor 
capitalized  was  worth  five  times  all  other  capital." 

Engel  computed  that  each  child  costs  100  marks  at  birth,  110  marks 
the  first  year,  120  the  second,  and  so  on.  At  20  he  will  have  cost 
2,310  marks,  or  $560.  But  one-half  die  before  20.  Hence  each  per- 
son who  reaches  the  age  of  20  actually  costs  society  much  more  than 
$560;  possibly  as  high  as  $1,000,  if  Engel's  estimates  are  correct. 
Professor  Mayo-Smith  estimated  that  men  and  women  between  the 

"See  "The  Living  Capital  of  the  United  Kingdom,"  (British)  Economic 
Journal,  1891. 

84369— No.  30—09 9 


118 


EEPOKT  ON   NATIONAL  VITALITY. 


ages  of  15  and  45  averaged  $1,000  in  value.*^  As  to  the  value  of  immi- 
grants to  this  country,  he  says :  "  Every  immigrant  must  represent 
labor  value  with  at  least  the  value  of  a  slave.  It  is  figured  that  each 
immigrant  is  worth  $875."  ^ 

The  best  method  of  estimating  the  economic  value  of  life  and  its 
increased  duration  is  by  the  capitalization  of  earning  power.  Dr. 
William  Farr,  of  England,  has  estimated  that  a  baby  born  to  an 
English  agricultural  laborer  is  worth  in  capitalized  earning  power 
about  £5,  or  $25.  This  is  the  discounted  value  of  its  future  earnings 
estimated  on  its  probable  life  less  the  discounted  value  of  the  cost 
of  rearing  it  during  the  period  of  dependence  and  of  maintaining 
it  when  helpless  through  old  age.  In  the  same  way  he  estimates  the 
value  of  a  life  at  other  ages — 10  years,  20  years,  50  years,  etc.*' 

In  lieu  of  any  estimates  for  the  United  States  we  may  take  Farr's 
figures  for  agricultural  laborers  as  representing,  roughly,  the  rela- 
tive worth  of  a  man  or  woman  in  the  United  States.  To  obtain  the 
absolute  figures,  therefore,  we  need  simply  to  multiply  these  of  Farr 
by  a  constant  factor  representing  the  ratio  between  the  average  earn- 
ings in  the  United  States  and  the  earnings  which  Farr  uses  as  the 
yearly  income  of  an  agricultural  laborer. 

"We  take,  in  the  absence  of  any  good  statistics,  $700  per  annum  as 
a  guess,  but  a  safe  minimum  ^  for  the  average  earnings  of  workers  of 
all  grades,  from  day  laborers  to  railroad  presidents.  This  assumes 
that  all  of  the  working  years  are  actually  employed  in  work.  But 
since  about  one-fourth  of  the  persons  of  working  age  are  not  workers, 
but  are  supported  (for  the  most  part)  by  earnings  of  capital,  the 
average  should  be  cut  down  to  three-fourths  of  this  figure,  or  $525. 

Substituting  this  figure  for  the  £31  in  Farr's  table,  we  can  recon- 
struct it  to  represent  the  minimum  worth  of  the  average  American 
life  at  different  ages.  The  following  figures  are  taken  from  the 
table  thus  computed : 


Age. 

Net 

worthofa 

person,  in 

dollars. 

Age. 

Net 

worthofa 

person,  in 

dollars. 

0 

90 

950 

2,000 

4,000 

30 

4,100 

5               

50.. 

2,900 

10                                                           

80 

-700 

20                              

From  the  table  from  which  these  figures  are  taken  it  is  possible  to 
base  minimum  estimates  for  (1)  the  average  economic  value  of  the 
inhabitants  of  the  United  States  by  using  the  census  figures  for  age 

o  Mayo-Smith,  "  Statistics  and  Sociology,"  p.  177. 

*  Mayo- Smith,  "  Emigration  and  Immigration." 

«  See  Farr,  "  Vital  Statistics,"  p.  536. 

•^  See  Fisher  "  Cost  of  tuberculosis,"  read  before  the  International  Congress 
on  Tuberculosis,  Washington,  1908.  This  is  the  estimated  minimum  used  in 
my  paper  on  the  "  Cost  of  tuberculosis."  The  calculations  are  based  on  $1  a 
day  as  the  ordinary  minimum  earnings  of  unskilled  labor,  and  assume  a  dis- 
tribution of  a  number  of  earners  of  high  amounts  according  to  the  scale  of 
distribution  which  Professor  Pareto  finds  fairly  uniform  in  form,  although  not 
in  amount  in  various  countries.  The  late  Honorable  Carroll  D.  Wright,  whose 
opinion  was  worth  more,  probably,  than  that  of  any  other  man  in  the  United 
States,  stated  that  he  would  not  regard  $1,000  as  excessive.  The  figure  is 
intended  to  include  the  earnings  of  women  (including  housewives  as  earners). 


EEPORT   ON    NATIONAL  VITALITY.  119 

distribution  of  population;  this  calculated  average  is  $2,900;  (2)  the 
average  economic  value  of  the  lives  now  sacrificed  by  preventable 
deaths,  using  the  age  distribution  of  deaths,  and  the  percentages  of 
preventability ;  this  calculated  average  is  $1,700. 

The  first  figure  shows  that  what  might  be  called  the  vital  assets  of 
the  United  States  for  the  population  of  over  85,500,000,  as  estimated 
by  the  census  of  1907,  amount  in  value  to  85,500,000 X$2,900,  or 
$250,000,000,000,  which,  though  a  minimum  estimate,  greatly  ex- 
ceeds the  value  of  all  other  wealth ;  °  the  second  figure  enables  us  to 
estimate  the  needless  waste  of  our  vital  assets. 

If  we  take  the  estunate  of  Professor  Willcox  of  the  death  rate  in 
the  United  States,  as  at  least  18  per  1,000  for  the  85,500,000  persons 
estimated  by  the  census  as  the  population  of  the  United  States  in 
1907,  we  have  1,500,000  as  the  number  of  deaths  in  the  United  States 
per  annum.  Of  these  1,500,000  deaths,  42  per  cent,  or  630,000,  are 
annually  preventable  or  postponable.  Since  each  postponement 
would  save  on  the  average  $1,700,  the  national  annual  unnecessary 
loss  of  capitalized  net  earnings  is  630,000X$1,700,  or  $1,070,000,000, 
or  about  $1,000,000,000. 

We  saw  in  Chapter  III  that,  with  our  present  population,  there 
are  always  about  3,000,000  persons  in  the  United  States  on  the  sick 
list.  For  the  most  part  these  persons  are  older  than  the  average. 
Farr  gives  a  table  ^  showing  that  morbidity  increases  with  age  in 
geometric  progression.  By  means  of  his  table  we  may  calculate  on 
the  same  basis  as  the  previous  calculations — that  of  the  3,000,000 
sick,  very  close  to  a  third,  or  1,000,000  persons,  are  in  the  working 
period  of  life.  Assuming  that  average  earnings  in  the  working 
period  are  $700,  and  that  only  three-fourths  of  the  one  million  poten- 
tial workers  would  be  occupied,  we  find  over  $500,000,000  as  the  mini- 
mum loss  of  earnings. 

The  cost  of  medical  attendance,  medicine,  nursing,  etc.,  is  con- 
jectured by  Doctor  Biggs  in  New  York  to  average  for  the  con- 
sumptive poor  at  least  $1.50  per  day  of  illness. .  The  cost  per  day  of 
other  illnesses  than  tuberculosis  is  presumably  greater,  and  also  the 
cost  per  day  for  other  classes  is  higher  than  for  the  poor.  Applying 
this  to  the  3,000,000  years  of  illness  annually  experienced,  we  should 
have  $1,500,000,000  in  all  as  the  minimum  annual  cost  of  this  kind. 

The  statistics  of  the  Commissioner  of  Labor  °  show  that  the  average 
expenditure  for  illness  and  death  amount  to  $27  per  annum.  This 
is  for  workingmen's  families  only.  But  even  this  figure,  if  applied 
to  the  17,000,000  families  of  the  United  States,  would  make  the  total 
bill  for  caring  for  illness  and  death  $460,000,000.  The  true  cost  may 
well  be  more  than  twice  this  sum.  Certainly  this  estimate  is  more 
than  safe  and  is  only  one-third  of  the  sum  obtained  by  using  Doctor 
Biggs's  estimate. 

The  sum  of  the  costs  of  illness,  including  loss  of  wages  and  cost  of 
Qare,  is  thus  $460,000,000+$500,000,000,  or  $960,000,000. 

The  above  estimate  is  a  general  one  for  all  illness.  It  would  be 
possible  to  offer  figures  for  the  particular  losses  from  particular  dis- 

"  Mr.  Le  Grand  Powers,  of  the  Bureau  of  the  Census,  Washington,  estimates 
that  the  total  wealth  in  America  (exclusive  of  human  beings)  amounts  to 
$107,000,000,000. 

*  Vital  Statistics,  p.  510. 

<'  Eighteenth  Annual  Report,  1903,  p.  509. 


120  KEPOKT    ON    NATIONAL   VITALITY. 

eases.  Thus,  from  tuberculosis,  the  gross  loss  of  earnings  by  illness 
and  of  potential  earnings  cut  off  by  death,  together  with  the  expenses 
of  illness,  etc.,  amount  to  over  $1,000,000,000  per  annum.'* 

Of  the  sum  mentioned,  the  loss  to  the  consumptives  themselves 
amounts  to  over  $660,000,000,  leaving  $440,000,000  as  the  loss  to  other 
members  of  the  community.  At  least  three-fourths  of  these  costs 
are  preventable.  Dr.  George  M.  Kober  thinks  it  is  conservative  to  say 
that  the  annual  cost  of  typhoid  in  the  United  States  is  $350,000,000  ^ 
and  Dr.  L.  O.  Howard  believes  that  malaria  alone  costs  the  country 
$100,000,000  annually,  and  the  insect  diseases  generally  $200,000,000.« 
He  points  out  that  one  great  item  of  loss  is  the  reduced  value  of  real 
estate  in  malarial  regions.  By  drainage  and  destruction  of  mos- 
quitoes most  of  this  waste  could  be  saved.  The  cost  of  the  care  of  the 
insane  and  feeble-minded  is  estimated  by  Charles  L.  Dana  at  $85,- 
000,000  annually.*^  What  fraction  of  these  costs  is  preventable  it  is 
difficult  to  say.  The  economic  loss  due  to  alcohol  has  been  variously 
estimated.^  Of  the  billion  dollars  or  more  found  to  represent  the  cost 
of  illness,  by  far  the  major  part  is  certainly  avoidable.  This  is  the 
belief  of  the  best  observers,  such  as  Doctor  Gulick,  Doctor  Kellogg, 
Mrs.  Eichards,  Doctor  Anderson,  and  others.  Unfortunately  there 
are  no  exact  statistics  of  preventability.  We  feel  safe,  however,  in 
concluding  that  at  least  half  a  billion  could  be  saved  from  the  pres- 
ent cost  of  illness.  This,  added  to  the  loss  by  preventable  deaths 
of  potential  earnings  of  a  billion,  gives  at  least  a  billion  and  a  half 
of  preventable  waste.  This  does  not  include  the  losses  from  inef- 
ficient work  due  to  drunkenness  or  other  vicious  habits;  nor  does 
it  include  the  cost  of  "  undue  fatigue,"  which  we  have  some  reason 
to  believe  exceeds  in  its  effect  on  efficiency  the  loss  from  illness.  But 
it  would  not  be  possible  to  state  this  loss  in  any  definite  or  convincing 
figures. 

The  actual  economic  saving  annually  possible  in  this  country  by 
preventing  needless  deaths,  needless  illness  (serious  and  minor),  and 
needless  fatigue,  is  certainly  far  greater  than  one  and  a  half  billions, 
and  may  be  three  or  more  times  as  great. 

Dr.  George  M.  Gould  estimated  that  sickness  and  death  in  the 
United  States  cost  $3,000,000,000  annually,  of  which  at  least  a  third 
is  regarded  as  preventable.'' 

The  trouble  is  the  public  does  not  believe  in  this  waste  from  being  "just 
poorly,"  and  "  so  as  to  be  about."  It  has  no  conception  of  the  difference 
between  working  with  a  clear  brain  and  steady  hand  and  with  a  dull  and 
nerveless  tool.     They  must  be  convinced  somehow.^ 

^  See  Irving  Fisher :  "  Cost  of  Tuberculosis  in  the  United  States,  and  its 
Reduction." 

6  See  his  "  Conservation  of  life  and  health  by  improved  water  supply,"  read 
before  the  White  House  Conference  of  Governors,  1908. 

^  Report  to  Conservation  Commission  on  "  Economic  loss  to  the  people  of  the 
United  States  through  insects  that  carry  disease." 

^  See  "  Psychiatry  in  its  relation  to  other  sciences,"  by  Charles  L.  Dana,  before 
the  section  on  psychiatry  at  the  International  Congress  of  Arts  and  Sciences, 
St.  Louis,   September,  1904. 

«  "  Economic  aspects  of  the  liquor  problem."  An  investigation  made  for  the 
Committee  of  Fifty,  under  the  direction  of  Henry  W.  Farnam,  secretary  of  the 
economic  subcommittee,  1899,  327  pages. 

f "  Disease  and  Sin,"  American  Medical  Journal,  August  31  and  September 
7,  1901. 

0  Letter  from  Ellen  H.  Richards. 


.     EEPORT   ON    NATIONAL  VITALITY.  121 

Section  2. — The  cost  of  conservation. 

It  costs  no  more  to  "  raise  "  a  man  capable  of  living  for  80  years  than  it  does 
to  "  grow  "  one  who  has  not  the  capacity  of  living  to  be  40  years  old." 

We  have  seen  how  much  potential  value  of  life  is  now  allowed  to 
be  wasted  which  could  be  prevented.  But  the  question  remains,  What 
would  it  cost  to  conserve  it?  It  is,  of  course,  not  possible  to  answer 
this  question  definitely  and  fully.  The  best  we  can  do  is  to  point  out 
specific  instances  of  the  health  returns  which  follow  on  investments 
in  the  improvement  of  vital  conditions. 

The  following  examples  will  show  the  returns  which  may  be  ex- 
pected from  well-planned  expenditures  on  behalf  of  public  health : 

The  city  of  Pittsburg  is  just  installing  a  great  municipal  filter  plant  for  the 
purification  of  its  principal  water  supply,  at  an  expense  of  upward  of  $7,000,000. 
It  is  reasonable  to  estimate  that  in  a  year  or  two  this  should  effect  a  saving  of 
100  deaths  a  year  from  typhoid  fever,  for  the  number  of  typhoid-fever  deaths 
of  late  years  has  been  400  or  more  yearly.  Valuing  these  lives  at  $5,000  each, 
as  is  customary,  the  saving  effected  by  the  purification  works  should  be  half  a 
million  dollars'  worth  of  human  life  annually,  making  the  building  of  the  filter 
a  sound  and  profitable  economic  as  well  as  humanitarian  measure.  But  if,  as 
Mr.  MacNutt  and  I  have  shown,  Hazen's  theorem  is  true,  then  for  every  100 
deaths  saved  from  typhoid  fever  at  least  200  will  be  saved  from  other  causes, 
which  means  at  least  $1,000,000  more  saved  to  the  city  of  Pittsburg  annually  of 
its  present  waste  of  human  life.^ 

England  reckons  that  the  lives  saved  through  the  lowered  death  rate,  from 
what  it  was  between  1866  and  1875  to  what  it  became  in  the  period  reaching 
from  18S0  to  1889,  amounted  to  858,804.  This  represents  on  the  English  basis 
of  the  per  capita  valuation  of  each  life  ($770)  a  social  capital  of  $650,000,000 
saved.  In  ten  years  England  has  more  than  regained  the  sum  spent  in  fifteen 
years  for  sanitary  improvements,  though  the  average  annual  expenditure  has 
been  $42,000,000.'' 

The  achievement  of  Huddersfield,  England,  is  especially  noteworthy.  The 
average  number  of  deaths  of  infants  for  ten  years  had  been  310.  By  a  system- 
atic education  of  mothers  the  number  was  in  1907  reduced  to  212.  The  cost  of 
saving  these  98  lives  was  about  $2,000.^^ 

A  saving  of  infant  life  is  recorded  by  Doctor  Chapin  in  Providence : 

We  attempted  for  two  years  to  distribute  clean  milk  "to  the  babies  of  the  poor, 
but  this  year  we  decided  that  the  money  could  better  be  spent  on  trained 
nurses.  Thus  far  we  have  expended  about  $900  for  this  purpose.  Two  hundred 
and  thirty-five  sick  children,  of  whom  very  many  were  very  sick,  have  been 
cared  for.  Of  these  only  20  have  died.  From  a  study  of  our  statistics  I  should 
judge  that  the  reduction  in  infant  mortality  effected  by  the  nurses  was  at  least 
25  deaths,  and  it  may  be  that  as  many  as  40  lives  were  saved." 

At  the  funeral  of  Maj.  Walter  Reed,  the  man  who  did  so  much  to 
prove  the  correctness  of  Doctor  Finley's  discovery  that  the  mosquito 
is  the  carrying  agent  for  the  yellow-fever  germ.  Gen.  Leonard  Wood 

"  T.  S.  Lambert :  "  Sources  of  Longevity,"  New  York,  1869,  p.  6. 

6  W.  T.  Sedgwick :  "  The  call  to  public  health,"  Science,  1908,  p.  198. 

Since  the  foregoing  was  written,  there  has  appeared  in  "  Charities,"  February 
6, 1909,  "  Thirty  Five  Years  of  Typhoid  "  by  Frank  E.  Wing,  in  which  it  is  shown 
that  there  were  in  1907,  in  Pittsburg,  4,921  cases  of  typhoid,  of  which  622  died ; 
and  that  the  cost  per  patient,  irrespective  of  the  lives  lost,  was  $128,  making  the 
cost  for  the  city  $694,000.  Beckoning  $4,000  as  the  value  of  each  life  lost, 
the  total  annual  money  cost  from  typhoid  in  Pittsburg  is  over  $3,000,000,  and, 
according  to  Hazen's  theorem,  already  mentioned,  this  is  probably  not  one-half 
nor  even  one-third  of  the  total. 

'^  Ditman,  loc.  cit.,  p.  4.  Taken  from  M.  G.  Dana :  "  Results  of  municipal 
sanitation,"  Annals  of  Hygiene,  1896,  Vol.  II,  p.  391. 

<*  Letter  from  Dr.  Charles  V.  Chapin. 

e  Ibid. 


122  EEPOET   ON   NATIONAL  VITALITY. 

declared  that  this  discovery  is  saving  more  lives  annually  than  were 
lost  in  the  Cuban  war,  and  that  it  is  saving  the  commercial  interests 
of  the  world  a  greater  financial  loss  each  year  than  the  cost  of  the 
entire  Cuban  war.*^ 

As  to  what  the  stamping  out  of  yellow  fever  means,  in  money 
terms,  the  following  is  significant : 

It  has  been  estimated  that  the  yellow  fever  epidemic  of  1878  invaded  132 
towns,  caused  a  mortality  of  15,954  persons,  and  that  the  pecuniary  loss  to  the 
country  was  not  less  than  $100,000,000  in  gold.* 

The  economic  loss  to  Philadelphia,  caused  by  the  smallpox  epidemic 
of  1871-72,  has  been  estimated  by  Doctor  Lee  at  $22,000,000.  This  in- 
cludes loss  to  travel  and  traffic  on  railroads,  loss  to  hotel  keepers, 
merchants,  and  manufacturers,  cost  of  care  of  sick,  loss  of  time,  and 
the  expense  of  burial.  A  vaccine  bureau  with  physicians,  a  disinfect- 
ing station,  and  the  inauguration  of  a  campaign  of  education  capable 
of  forestalling  the  whole  epidemic  would  have  cost  $700,000.*' 

It  is  reported  that  San  Francisco  plans  an  investment  of  $30,000,- 
000  in  stone  and  concrete  quays  to  prevent  rodents  from  infecting  the 
city,  and  this  is  regarded  by  experts  as  worth  while  many  times  over. 

In  respect  to  hook-worm  disease,  rating  the  earning  per  diem  of  the 
southern  farm  laborer  at  75  cents,  28  observers  report  that  average 
laborers  infected  with  hook-worms  earn  40  cents  per  diem.  Ten  ob- 
servers having  cotton-mill  practice  report  unanimously  that  the 
disease  is  very  prevalent  among  cotton-mill  laborers,  and  rating  the 
average  mill  laborers  at  $1.50  per  diem,  they  consider  75  cents  as  a 
fair  rating  for  hook-worm  bearing  laborers.* 

It  would  be  difficult  to  even  roughly  estimate  the  cost  of  this  disease  to  the 
South,  but  from  what  we  know  of  it  in  this  State  I  would  say  that  it  costs  South 
Carolina  not  less  than  $30,000,000  per  year,  and  this  inability  to  perform  regular 
and  efficient  labor  is  the  smallest  part  of  the  cost.* 

It  has  been  figured  that  the  hook-worm  disease  of  the  South  could 
be  wiped  out  within  a  generation  f  through  the  expenditure  of  from 
one  to  two  millions  of  dollars  by  federal  and  state  agencies.  It  costs 
about  15  to  75  cents  (wholesale)  for  drugs  to  cure  a  case  of  hook 
worms.  In  three  months  the  quantity  of  red  corpuscles  in  the  blood 
can  easily  be  increased  10  to  50  per  cent,  according  to  the  severity  of 
the  case,  and  the  ^  absenteeism  of  the  victims  could  easily  be  reduced 
25  per  cent. 

Another  noteworthy  result  of  well-directed  sanitary  effort  is  the  reduction  of 
hook-worm  disease  in  Porto  Rico.  As  you  are  doubtless  aware,  this  disease 
causes  a  tremendous  lowering  of  the  physical  efficiency  of  the  people  of  that 
island.  As  you  may  see  by  the  report  of  the  special  commission  for  1906  and 
1907  made  to  Governor  Post,  89,000  people  were  treated,  and  for  the  most 
part  cured,  for  54  cents  each.'' 

"Ditman,  loc.  cit,  p.  12. 

^  Walter  Wyman,  M.  D.,  "  Quarantine  and  Commerce,"  address  before  Cincin- 
nati Commercial  Club,  October  15,  1898,  p.  8. 

c  Ditman,  loc.  cit,  pp.  8-10,  from  Bissell,  A  Manual  of  Hygiene. 

*  Letter  from  Dr.  W.  J.  Burdell. 

e  William  Weston,  "  Uncinariasis,"  South  Carolina  Medical  Association,  1908, 
p.  8. 

f  Dr.  Charles  W.  Stiles,  of  the  United  States  Public  Health  and  Marine-Hos- 
pital Service,  who  has  studied  the  hook-worm  disease  more  thoroughly  than  any 
one  else  in  the  country. 

i>  Letter  from  Doctor  Stiles. 

''Letter  from  Charles  V.  Chapin,  1908. 


KEPOET   ON    NATIONAL  VITALITY.  123 

Medical  inspection  in  our  schools  also  returns  large  dividends  on 
small  investments. 

Using  these  data  as  a  basis,  we  have  the  annual  expenditure  for  medical 
Inspection  of  $345,135  in  those  cities  from  which  we  have  succeeded  in  obtain- 
ing data.  It  seems  probable,  although  this  is  frankly  a  guess,  that  the  total 
annual  expenditure  for  medical  inspection  of  schools  in  the  United  States  at 
the  present  time  is  perhaps  $500,000.'' 

The  money  saved  by  enabling  thousands  of  children  to  do  one  year's  work  in 
one  year,  instead  of  in  two  or  three  years,  would  greatly  exceed  the  total 
expense  of  examining  all  school  children  in  all  boroughs.^ 

Doctor  Jessen  has  shown  that  the  cost  of  a  school  dental  clinic  in 
Germany  is  only  one  mark  per  year  per  child."  The  cost  saved  must 
be  very  many  times  this  sum.  Dr.  Herbert  L.  Wheeler,  of  New 
York,  estimates  that  the  Children's  Aid  Dental  Clinic  in  New  York 
cost  $342  for  the  last  fiscal  year  (35  cents  per  operation  and  70  cents 
per  child  treated) .  He  reckons  that  the  neglect  of  these  slight  repairs 
would  later  have  cost  far  more  in  dentistry,  as  well  as  over  $2,000 
worth  of  lost  time.  These  losses  are  of  course  of  minor  importance 
compared  with  the  pain,  inconvenience,  and  secondary  effects  on 
health  and  efficiency  which  are  inevitably  associated  with  bad  teeth. 

Mr.  Edwin  Chadwick,  who  was  once  secretary  of  the  English  Na- 
tional Board  of  Health,  stated  that  a  sanitary  "  engineer  ought  to 
contract  for  the  reduction  of  the  sickness  and  death  rate,  in  such  a 
city  as  Glasgow,  by  at  least  one-third,  for  a  penny  a  head  of  the 
entire  population."  ^ 

It  Is  necessary,  if  we  are  to  do  our  utmost,  to  spend  a  thousand  pounds  of 
public  money  on  this  task  where  we  now  spend  one  pound.  It  would  be  rea- 
sonable and  wise  to  expend  ten  million  pounds  a  year  of  our  revenues  on  the 
investigation  and  attempt  to  destroy  disease.  Actually  what  is  so  spent  is  a 
mere  nothing,  a  few  thousands  a  year.  Meanwhile  our  people  are  dying  by 
thousands  of  preventable  disease.^ 

Mr.  Hiram  J.  Messenger,  actuary  of  the  Travelers  Insurance  Com- 
pany, of  Hartford,  has  constructed  and  sent  me  a  table  showing  that 
life  insurance  companies  could  probably  make  money  now  by  taking 
a  hand  in  the  public-health  movement,  with  the  purely  commercial 
object  of  reducing  their  death  losses.     He  says : 

This  table  shows  that  if  the  companies  were  to  expend  $200,000  a  year  for 
this  purpose  and  as  a  result  should  decrease  their  losses  by  the  almost  insig- 
nificant amount  of  twelve  one-hundredths  of  1  per  cent,  they  would  save  enough  to 
cover  the  expense.  If  such  a  plan  as  this  were  placed  on  a  purely  scientific  basis 
and  carried  out  by  good  business  methods  and  all  the  companies  pulled  together 
for  the  common  good,  I  should  expect  a  decrease  in  death  claims  of  more  than  1 
per  cent.  And  a  decrease  in  death  claims  of  1  per  cent  would  mean  that  the 
companies  would  save  more  than  eight  times  as  much  as  they  expended  or  would 
make  a  net  saving  of  more  than  seven  times  the  expense — which  would  be  about 
a  million  and  a  half  dollars  a  year. 

The  examples  given  show  tangible  returns  on  the  investment  of  sev- 
eral thousand  per  cent  as  a  rule.     While  it  would  be  impossible  to 

"  Letter  from  Dr.  Luther  H.  Guliek. 

^  Sixty-third  Annual  Report  of  the  Association  for  Improving  the  Condition  of 
the  Poor,  New  York,  1906. 

<'  See  "Jahresbericht  der  Stadtischen  Schulzahnklinik  in  Strassburg,"  in 
Odontologische  Blatter  12,  No.  15-16,  1907. 

<*  Transactions  of  the  British  Social  Science  Association,  1866,  p.  580.  Quoted 
by  Dr.  Edward  Jarvis,  Political  Economy  of  Health,  Fifth  Report,  Mass.  Board 
of  Health,  1874,  p.  367. 

«E.  Ray  Lankester,  "The  Kingdom  of  Man,"  New  York  (Holt),  1907,  p.  148. 


124  KEPOKT   ON    NATIONAL  VITALITY. 

state  in  general  terms  how  rich  a  return  lies  ready  for  public  or  pri- 
vate investments  in  good  health,  the  foregoing  examples  and  numer- 
ous others  show  that  the  rate  of  this  return  is  quite  beyond  the  dreams 
of  avarice.  "Were  it  possible  for  the  public  to  realize  this  fact,  motives 
both  of  economy  and  of  humanity  would  dictate  immediate  and  gen- 
erous expenditure  of  public  moneys  for  improving  the  air  we  breathe, 
the  water  we  drink,  and  the  food  we  eat,  as  well  as  for  eliminating 
the  dangers  to  life  and  limb  which  now  surround  us. 

Chapter  XIII. — The  general  value  of  increased  vitality. 
Section  1. — Disease,  poverty,  and  crime. 

In  the  preceding  chapter  we  have  attempted  to  estimate  in  money 
the  preventable  wastes  from  disease  and  death.  Although  the  figures 
for  national  losses  strike  the  popular  imagination,  they  have  little 
significance ;  in  fact,  money  estimates  in  this  field,  even  when  made  on 
the  per  capita  basis,  are  of  little  value  except  as  emphasizing  the 
overwhelming  importance  of  human  vitality  compared  with  those 
interests  which  are  usually  measured  in  money.  It  is  impossible  in 
any  true  sense  to  measure  human  life  in  terms  of  dollars  and  cents." 

The  measure  of  life  may  perhaps  be  found  in  happiness,  or  the 
satisfactions  enjoyed  between  birth  and  death,  less  the  dissatisfactions. 

Is  life  worth  living  ?  has  been  a  much  asked  question,  especially  since 
Mr.  Mallock  wrote  a  book  with  that  title.  The  witticism  sometimes 
given  in  answer,  "  That  depends  upon  the  liver,"  is  true  in  both  of  its 
two  meanings.  A  life  of  happiness  is  always  worth  living,  and  a  life 
of  usefulness,  which  brings  happiness  to  others,  is  doubly  worth 
living. 

It  is  hardly  necessary  to  recount  all  the  conditions  which  tend  to 
produce  happiness.  No  one  would  question  that  the  most  funda- 
mental condition  of  all  is  health,  in  spite  of  exceptional  cases  in  which 
unhealthy  people  are  found  happy,  and  healthy  people  unhappy.  It 
would  be  impossible  to  express  in  exact  terms  the  extent  to  which  im- 
proved health  could  increase  human  happiness;  but  every  observer 
of  human  misery  among  the  poor  reports  that  disease  plays  the  lead- 
ing role.  Students  of  criminology  and  vice  agree  that  these  are 
chiefly  the  result  of  morbid  conditions  and  habits.  Health  reform 
brings  in  its  train  great  and  lasting  reductions  in  poverty,  criminality, 
and  vice.  ^ 

We  began  this  report  by  showing  the  relation  between  the  conser- 
vation of  health  and  the  conservation  of  wealth.  The  broadest  view 
of  this  relation  is,  as  Emerson  has  said,  that  "Health  is  the  first 
wealth,"  and  as  such  it  is  treated  by  many  economists.^ 

<^  Even  as  a  measure  of  what  economists  call  "  utility,"  a  money  estimate  is 
misleading,  for  the  reason  that  the  "  marginal  utility  "  of  money  varies  with 
different  persons.  For  instance,  a  week's  wages  of  $10  lost  to  a  poor  wage- 
earner  is  in  such  an  estimate  counted  on  a  par  with  an  expenditure  of  $10  by 
a  wealthy  invalid  for  a  dainty  morsel  of  food,  although  the  loss  in  "  utility  " 
to  the  former  is  vastly  greater  than  that  to  the  latter. 

^Among  those  who  have  included  health  in  the  category  of  wealth  are 
Davenant,  Petty,  Canard,  Say,  McOullough,  Roscher,  Wittstein,  Walras,  Engel, 
Weiss,  Dargun,  Ofner,  Nicholson,  and  Pareto.  See  Irving  Fisher :  "  The  Nature 
of  Capital  and  Income."  New  York  (Macmillan),  1906,  p.  5. 


KEPORT   ON    NATIONAL  VITALITY,  125 

Without  enlarging  or  insisting  upon  this  concept,  it  is  obvious  that 
by  the  conservation  of  health  we  may  ultimately  save  billions  of 
dollars  of  wasted  values,  and  that  this  conservation  is  intimately 
related  to  conservation  of  all  other  kinds.* 

"We  have  already  seen  the  vicious  circle  set  up  between  poverty  and 
disease,  each  of  which  tends  to  produce  the  other.  Metchnikoff  ^  con- 
tends that  health  and  morality  are  correlative,  if  not  interchangeable, 
terms.  A  similar  idea  has  been  elaborated  statistically  by  Dr.  George 
M.  Gould."  The  subject  is  worth  much  further  study.  National 
efficiency  is  crippled  by  any  one  or  all  of  the  parts  of  the  vicious 
circle — disease,  poverty,  vice,  vagabondage,  crime.  It  would  be 
interesting  to  study  the  tramp  problem,  which  represents  an  enor- 
mous waste  of  labor  power,  in  relation  to  all  these  phenomena. 

Section  2. — Conservation  of  natural  resources. 

It  is  also  true  that  health  begets  wealth,  and  vice  versa.  Whatever 
diminishes  poverty  or  increases  the  physical  means  of  welfare  has  the 
improvement  of  health  as  one  of  its  first  and  most  evident  effects. 
Therefore  an  important  method  of  maintaining  vital  efficiency  is  to 
conserve  our  natural  resources — our  land,  our  raw  materials,  our  for- 
ests, and  our  water.  Only  in  this  way  can  we  obtain  food,  clothing, 
shelter,  and  the  other  means  of  maintaining  life.  Conversely,  the 
conservation  of  health  will  tend  in  several  ways  to  the  conservation 
of  wealth.  First  of  all,  the  more  vigorous  and  long-lived  the  race, 
the  better  utilization  can  it  make  of  its  natural  resources.  The  labor 
power  of  such  a  race  is  greater,  more  intense,  more  intelligent,  and 
more  inventive. 

The  development  of  our  natural  resources  in  the  future  will  be 
more  dependent  on  technical  invention*^  than  upon  the  mere  abun- 
dance of  materials. 

Just  as  in  warfare  it  is  not  so  much  the  gun  as  the  man  behind 
the  gun  that  makes  for  success,  so  in  industry,  as  Doctor  Shadwell  ® 
has  shown,  skill,  knowledge,  and  inventiveness  are  the  chief  factors 
in  determining  commercial  success  and  supremacy.  The  backward 
nations,  like  China,  are  characterized  by  lack  of  modern  inventions. 
The  nations  which  are  industrially  most  advanced  have  the  railway, 
the  steamship,  the  power  loom,  metal  working,  and  innumerable  arts 
and  crafts.  The  change  of  Japan  from  a  backward  to  a  forward 
nation  is  at  bottom  the  introduction  of  inventions.  If  conservation 
prevents  lessened  fertility,  invention  makes  two  blades  of  grass  grow 
where  one  grew  before. 

Future  industrial  competition  will  be  increasingly  a  contest  of  in- 
vention. The  world  rivalry  to  develop  the  best  system  of  wireless 
telegraphy  or  the  best  airships  is  but  one  example.  The  future  will 
see  the  greatest  strides  taken  by  the  nation  which  is  the  most  invent- 

<»See  Edward  Devine,  "Efficiency  and  Relief,"  New  York  (Macmillan),  1906. 

^  "  Prolongation  of  Life,"  p.  318. 

"  "  Disease  and  sin,"  American  Medical  Journal,  Aug.  31  and  Sept.  7,  1901. 

*  Since  the  above  was  written.  President  Charles  S.  Howe,  of  Cleveland,  has 
presented  this  point  in  detail.  See,"  The  function  of  the  engineer  in  the  con- 
servation of  the  natural  resources  of  the  country,"  Science,  Oct.  23,  1908. 

« Arthur  Shadwell  in  his  admirable  "Industrial  Efficiency"  (2  vols.).  Lon- 
don (Longmans),  1906. 


126  EEPOET   ON   NATIONAL  VITALITY. 

ive.  Now,  the  primary  condition  of  invention  is  vitality,  a  clear 
brain  in  a  normal  body.  It  is  no  accident  that  Edison  is  a  health 
culturist,  or  that  Krupp,  Westinghouse,  and  other  pioneers  in  indus- 
trial development  have  been  men  of  vigor  of  mind  and  body. 

Finally,  the  conservation  of  health  will  promote  the  conservation 
of  other  resources  by  keeping  and  strengthening  the  faculty  of  fore- 
sight. One  cause  of  poverty  in  the  individual  and  the  nation  is  lack 
of  forethought.** 

One  of  the  first  symptoms  of  racial  degeneracy  is  decay  of  fore- 
sight. Normal,  healthy  men  care  for  and  provide  for  their  descend- 
ants. A  normal,  healthy  race  of  men,  and  such  alone,  will  enact 
the  laws  or  develop  the  public  sentiment  needed  to  conserve  natural 
resources  for  generations  yet  unborn.  When  in  Eome  foresight 
was  lost,  care  for  future  generations  practically  ceased.  Physical 
degeneracy  brought  with  it  moral  and  intellectual  degeneracy.  In- 
stead of  conserving  their  resources  the  spendthrift  Romans,  from  the 
emperor  down,  began  to  feed  on  their  colonies  and  to  eat  up  their 
capital.  Instead  of  building  new  structures  they  used  their  old 
Coliseum  as  a  quarry  and  a  metal  mine.^ 

The  problem  of  the  conservation  of  our  natural  resources  is  there- 
fore not  a  series  of  independent  problems,  but  a  coherent  all-embra- 
cing whole.  If  our  nation  cares  to  make  any  provision  for  its  grand- 
children and  its  grandchildren's  grandchildren,  this  provision  must 
include  conservation  in  all  its  branches — ^but  above  all,  the  conserva- 
tion of  the  racial  stock  itself. 

Chapter  XIV. — Things  which  need  to  he  done. 
Section  1. — Enumeration  of  principal  measures. 

In  order  that  American  vitality  may  reach  its  maximum  devel- 
opment, many  things  need  to  be  done.  Among  them  are  the  fol- 
lowing: 

1.  The  National  Government,  the  States,  and  the  municipalities 
should  steadfastly  devote  their  energies  and  resources  to  the  protec- 
tion of  the  people  from  disease.  Such  protection  is  quite  as^  properly 
a  governmental  function  as  is  protection  from  foreign  invasion,  from 
criminals,  or  from  fire.  It  is  both  bad  policy  and  bad  economy 
to  leave  this  work  mainly  to  the  weak  and  spasmodic  efforts  of 
charity,  or  to  the  philanthropy  of  physicians. 

2.  The  National  Government  should  exercise  at  least  three  public 
health  functions:  First,  investigation;  second,  the  dissemination  of 
information;  third,  administration. 

It  should  remove  the  reproach  that  more  pains  are  now  taken  to 
protect  the  health  of  farm  cattle  than  of  human  beings.  It  should 
provide  more  and  greater  laboratories  for  research  in  preventive 
medicine  and  public  hygiene.  Provision  should  also  be  made  for 
better  and  more  universal  vital  statistics,  without  which  it  is  impos- 
sible to  know  the  exact  conditions  in  an  epidemic,  or,  in  general, 
the  sanitary  or  insanitary  conditions  in  any  part  of  the  country. 

"See  Irving  Fisher:  "The  Rate  of  Interest,"  New  York   (Macmillan),  1907. 
^See  John  Rae:  "Sociological  Theory  of  Capital,"  edited  by  Prof.  C.  W. 
Mixter,  New  York  (Macmillan),  1905. 


REPORT   ON    NATIONAL  VITALITY.  127 

It  should  aim,  as  should  state  and  municipal  legislation,  to  procure 
adequate  registration  of  births,  statistics  of  which  are  at  present 
lacking  throughout  the  United  States. 

The  National  Government  should  prevent  transportation  of  dis- 
ease from  State  to  State  in  the  same  way  as  it  now  provides  for 
foreign  quarantine  and  the  protection  of  the  nation  from  the  impor- 
tation of  disease  by  foreign  immigrants.  It  should  provide  for  the 
protection  of  the  passenger  in  interstate  railway  travel  from  infection 
by  his  fellow-passengers  and  from  insanitary  conditions  in  sleeping 
cars,  etc. 

It  should  enact  suitable  legislation  providing  against  pollution  of 
interstate  streams. 

It  should  provide  for  the  dissemination  of  information  in  regard 
to  the  prevention  of  tuberculosis  and  other  diseases,  the  dangers  of 
impure  air,  impure  foods,  impure  milk,  imperfect  sanitation,  ventila- 
tion, etc.  Just  as  now  the  Department  of  Agriculture  supplies 
specific  information  to  the  farmer  in  respect  to  raising  crops  or  live 
stock,  so  should  one  of  the  departments,  devoted  principally  to  health 
and  education,  be  able  to  provide  every  health  oflEicer,  school-teacher, 
employer,  physician,  and  private  family  with  specific  information  in 
regard  to  public,  domestic,  and  personal  hygiene. 

It  should  provide  for  making  the  national  capital  into  a  model 
sanitary  city,  free  from  insanitary  tenements  and  workshops,  air 
pollution,  water  pollution,  food  pollution,  etc.,  with  a  rate  of  death 
and  a  rate  of  illness  among  infants  and  among  the  population  gen- 
erally so  low  and  so  free  from  epidemics  of  typhoid  or  other  diseases 
as  will  arouse  the  attention  of  the  entire  country  and  the  world. 

There  should  be  a  constant  adaptation  of  the  pure-food  laws  to 
changing  conditions.  Meat  inspection  and  other  inspection  should  be 
so  arranged  as  to  protect  not  only  foreigners,  but  our  own  citizens. 
The  existing  health  agencies  of  the  Government  should  be  concen- 
trated in  one  department,  better  coordinated,  and  given  more  powers 
and  appropriations. 

3.  State  boards  of  health  and  state  legislation  should  provide  for 
the  regulation  of  labor  of  women,  should  make  physiological  condi- 
tions for  women's  work  and  prevent  their  employment  before  and 
after  childbirth;  should  regulate  the  age  at  which  children  shall  be 
employed,  make  reasonable  regulations  in  regard  to  hours  of  labor 
and  against  the  dangers  in  hazardous  trades,  and  especially  against 
the  particular  dangers  of  dust  and  poisonous  chemicals ;  should  make 
regulations  for  sanitation  and  provide  inspection  of  factories,  schools, 
asylums,  prisons,  and  other  public  institutions.  Where  municipalities 
have  not  the  powers  to  enact  the  legislation  above  mentioned  with 
reference  to  local  conditions,  the  necessary  legislation  or  authority 
should  be  provided  by  the  State.  Or  where  by  reason  of  the  small 
size  of  the  town  no  efficient  local  action  is  possible,  the  State  should 
exercise  the  necessary  functions.  It  should  in  such  cases  advise  and 
supervise  local  boards  of  health.  It  should  have  an  engineering  de- 
partment and  advise  regarding  the  construction  of  sewers  and  water 
supplies.  Pollution  of  such  supplies,  unless  entirely  local,  should  be 
prevented  by  the  State,  which  should  be  equipped  with  laboratories 
for  the  analysis  of  water,  milk,  and  other  foods.  Suitable  legislation 
should  be  passed  regulating  the  sale  of  drugs,  especially  preparations 


128  KEPORT   ON   NATIONAL  VITALITY. 

containing  cocaine,  opium,  or  alcohol.  Legislation — not  too  far  in 
advance  of  public  sentiment  needed  to  enforce  it — should  be  passed 
regulating  the  sale  of  alcoholic  beverages.  State  registration  of 
births,  deaths,  and  cases  of  illness  should  be  much  more  general  and 
efficient  than  at  present. 

4.  Municipal  boards  of  health  need  to  have  more  powers  and 
greater  appropriations;  less  political  interference  and  better  trained 
health  officers ;  more  support  in  public  opinion.  Their  ordinances  in 
regard  to  expectoration,  notification  of  infectious  disease,  etc.,  should 
be  better  enforced  by  the  police  departments. 

More  legislation  should  be  advocated,  passed,  and  enforced  to 
the  end  that  streets  may  be  kej3t  clean,  garbage  properly  removed, 
sewage  properly  disposed  of,  air  pollution  of  all  kinds  prevented, 
whether  by  smoke,  street  dust,  noxious  gases,  or  any  other  source. 
ISToises  also  should  be  lessened. 

Municipalities  need  also  to  take  measures  to  prevent  infection  being 
carried  by  flies,  mosquitoes,  other  insects  and  vermin,  and  by  prosti- 
tution. They  need  to  guard  with  greater  care  the  water  supply,  and 
in  many  cases  to  filter  it;  they  should  make  standards  for  milk  pu- 
rity and  enforce  them ;  they  should  also  regularly  inspect  other  foods 
exposed  for  sale;  provide  for  sanitary  inspection  of  local  slaughter- 
houses, dairies,  shops,  lodging  and  boarding  houses,  and  other  estab- 
lishments within  the  power  of  the  particular  municipality;  they 
should  make  and  enforce  stricter  building  laws,  especially  as  relating 
to  tenements,  to  the  end  that  dark-room  tenements  may  be  eliminated 
and  all  tenements  be  provided  with  certain  minimum  standard  re- 
quirements as  to  light,  air,  and  sanitary  arrangements. 

5.  School  children  should  be  medically  inspected  and  school 
hygiene  universally  practiced.  This  involves  better  protection 
against  school  epidemics,  better  ventilation,  light,  and  cleanliness  of 
the  schoolroom,  the  discovery  and  correction  of  adenoids,  eye  strain, 
and  nervous  strain  generally,  and  the  provision  for  playgrounds. 
Sound  scientific  hygiene  should  be  taught  in  all  schools,  public,  pri- 
vate, normal,  and  technical,  as  also  in  colleges  and  universities, 

6.  The  curricula  of  medical  schools  should  be  rearranged  with  a 
greater  emphasis  on  prevention  and  on  the  training  of  health  officers. 
Sanatoria  and  hospitals,  dispensaries,  district  nursing,  tuberculosis 
classes,  and  other  semipublic  institutions  should  be  increased  in  num- 
ber and  improved  in  quality.  The  medical  profession,  keeping  pace 
with  these  changes,  should  be  the  chief  means  of  conveying  their 
benefits  to  the  public.  Universities  and  research  institutions  need 
to  take  up  the  study  of  hygiene  in  all  its  branches.  Now  that  the 
diseases  of  childhood  are  receiving  attention,  the  next  step  should 
be  to  study  the  diseases  of  middle  life.  These  are  diseases,  to  a  large 
extent,  of  nutrition  and  circulation,  and  consequently  these  subjects 
should  receive  special  attention.  Intelligent  action  must  rest  on 
knowledge,  and  knowledge  of  preventing  disease  is  as  yet  extremely 
imperfect. 

7.  In  industrial  and  commercial  establishments  employers  may 
greatly  aid  the  health  movement,  and  in  many  cases  make  their  phi- 
lanthropy self-supporting  by  providing  social  secretaries,  lunch  and 
rest  rooms,  physiological  (generally  shorter)  hours  of  work,  pro- 
vision for  innocent  amusements,  seats  for  women,  etc. 


EEPORT   ON    NATIONAL,  VITALITY.  129 

Life  insurance  companies  could  properly  and  with  much  profit 
club  together  to  instruct  their  risks  in  self-care  and  secure  general 
legislation  and  enforcement  of  legislation  in  behalf  of  public  health. 

8.  The  present  striking  change  in  personal  habits  of  living  should 
be  carried  out  to  its  logical  conclusion  until  the  health  ideals  and  the 
ideals  of  athletic  training  shall  become  universal.  This  change  in- 
volves a  quiet  revolution  in  habits  of  living,  a  more  intelligent  utili- 
zation of  one's  environment,  especially  in  regard  to  the  condition  of 
the  air  in  our  houses,  the  character  of  the  clothes  we  wear,  of  the 
site  and  architecture  of  the  dwelling  with  respect  to  sunlight,  soil, 
ventilation,  and  sanitation,  the  character  of  food,  its  cooking,  the 
use  of  alcohol,  tobacco,  and  drugs,  and  last,  but  not  least,  sex  hygiene 
in  all  its  bearings. 

9.  The  fight  against  disease  will  aid  in  the  fight  against  pauper- 
ism and  crime.  It  is  also  true  that  any  measures  which  tend  to  elimi- 
nate poverty,  vice,  and  crime  will  tend  to  improve  sanitary  condi- 
tions. 

10.  Finally,  eugenics,  or  hygiene  for  future  generations,  should  be 
studied  and  gradually  put  in  practice.  This  involves  the  prohibi- 
tion of  flagrant  cases  of  marriages  of  the  unfit,  such  as  syphilitics, 
the  insane,  feeble-minded,  epileptics,  paupers,  or  criminals,  etc.  The 
example  of  Indiana  in  this  regard  should  be  considered  and  followed 
by  other  States,  as  also  in  regard  to  the  unsexing  of  rapists,  criminals, 
idiots,  and  degenerates  generally.  A  public  opinion  should  be 
aroused  which  will  not  only  encourage  healthy  and  discountenance 
degenerate  marriages,  but  will  become  so  embedded  in  the  minds  of 
the  rising  generation  as  will  unconsciously,  but  powerfully,  affect 
their  marriage  choices. 


INDEX. 


Abattoirs,  municipal  inspection  of  local,  58,  128. 

Abbott,  A.  C,  cited,  28. 

Abbott,  Samuel  W.,  vital  statistics  by,  16, 18, 26,103, 
113. 

Abdominal  congestion,  resulting  from  sedentary- 
occupations,  91,  96. 

Absinthe,  national  degeneration  in  France  from  use 
of,  89. 

Accidents,  industrial,  losses  from,  32,  37;  long  work- 
ing hours  a  cause  of,  46;  losses  from,  preventable 
only  by  state  legislation,  61;  prolongation  of 
life  by  protection  from,  107. 

Activity,  hygiene  of,  83,  90-92. 

Adams,  Samuel  H.,  pamphlet  by,  81. 

Adams,  T.  S.,  cited,  60. 

Adenoids,  effect  of,  73. 

Adults,  tendency  to  increase  of  death  rate  among, 
25-27. 

Advertisements,  harmful,  81. 

Age,  variation  of  death  rate  with,  25-27.  See  Old 
age. 

Ailments,  minor.    See  Minor  ailments. 

Air,  securing  purity  of,  in  cities,  56,  57,  128;  in  rail- 
way trains  and  street  cars,  62,  84;  sleeping  in 
open,  67,  82,  84;  the  ideal  state  of,  83;  filtration 
of,  in  stores  and  offices,  71,  80;  securing  pure,  in 
houses,  84-86. 

Air  baths,  86. 

Air  hygiene,  84-85, 107. 

Aitkin,  on  country  air  v.  City  air,  84. 

Alcohol,  as  a  cause  of  disease,  28,  88;  increase  in 
fatigue  due  to,  41-42;  treatment  of  subject  of, 
in  school  physiologies,  78;  percentage  of  poverty 
and  crime  caused  by,  89;  economic  loss  due  to, 
120;  state  regulation  of  sale  of,  128. 

Alcoholism,  as  cause  of  pneumonia.  28;  prevalence 
of,  36;  possible  prolongation  of  life  by  elimina- 
tion of,  105. 

Aldrich  report,  cited,  60. 

Allen,  William  H.,  "Civics  and  Health"  by,  55n.6 

America,  vital  statistics  in.    See  Massachusetts. 

American  Association  for  Labor  Legislation,  79. 

American  Health  League,  79. 

American  Medical  Association,  64,  65,  66. 

American  Physical  Education  Society,  79. 

American  Playground  Association,  79. 

American  Public  Health  Association,  64,  79. 

Amherst  College,  effects  of  tobacco  on  students  at, 
90. 

Amsterdam,  death  rate  in,  22. 

Anderson,  W.  G.,  on  smoking  among  students,  90n;  <» 
cited,  120. 

Andrews,  Champe  S.,  cited,  81. 

Angina  pectoris,  possible  prolongation  of  life  by 
elimmation  of,  105. 

Animals,  diseases  propagated  by,  57,  67. 

Annuities,  British  governmental,  17. 

Antiseptic  surgery,  65;  reform  in  midwifery  due  to, 
66. 

Antitoxin,  m.unicipal  distribution  and  administra- 
tion of,  58. 

Apoplexy,  increase  of  death  rate  from,  27;  syphilis 
may  lead  to,  93;  possible  prolongation  of  life 
by  elimination  of,  105. 

Appendicitis,  may  originate  in  tonsilitis,  39;  pos- 
sible prolongation  of  life  by  elimination  of,  104. 

Armies,  invalidity  in,  from  venereal  diseases,  36; 
results  of  antiseptic  surgery  in,  66. 

Army  hygiene,  importance  of,  63. 

Amer,  G.  B.  L.,  work  by,  SOn.a 

Arteriosclerosis,  increase  of,  27;  minor  ailments 
leading  to,  39. 


Arthritis,  may  originate  in  tonsilitis,  39. 

Aschaflenburg,  experiments  by,  42. 

Aseptic  surgery,  65. 

Asiatic  plague,  transmission  of,  by  rats,  57,67. 

Athletes,  smoking  among,  90n.o 

Athletics,  beneficial  effects  of  modern  devotion  to, 

51,91. 
At  water,  W.  O.,  88n.a 
Auto-intoxication,   causes  and    effects    of,  42-44; 

avoidance  of,  87. 
Ayres,  "Medical  Inspection  of  Schools"  by,  74. 

B. 

Babbage,  Charles,  quoted,  16;  on  effects  of  vaccina- 
tion, 29. 

Backward  children  in  schools,  73-75. 

Bacteriological  laboratories,  58, 126. 

Bailey,  H.  T.,  cited,  73. 

Baines,  J.  A.,  vital  statistics  of  India  by,  16,19,20. 

Baker,  Henry  B.,  estimates  by,  114. 

Ballentyne,  cited,  73. 

Bancroft,  Charles  P.,  cited,  71,73. 

Bardswell,  cited,  34. 

Barrow,  annual  health  day  proposed  by,  78. 

Baths,  public,  58;  value  of,  90-91. 

Beer,  effects  of,  41,42. 

Beers,  Clifford  W.,  work  by,  71n.a 

Belfast,  Ireland,  death  rate  in,  22. 

Belgium,  death  rate  from  smallpox  in,  29. 

Benedict,  F.  G.,  cited,  43. 

Berlin,  death  rate  in,  22;  lowering  of  death  rate  in, 
24. 

Biggs,  on  cost  of  sickness,  119. 

Bin^t,  laboratory  of,  72n.6 

"Biological  engineering,"  15. 

Birth  rate,  eflect  on,  of  voluntary  childlessness,  54 

Births,  registration  of,  63-64,127. 

Bising,  experiment  by,  44. 

Black  death,  the,  24. 

Black  Hole  of  Calcutta,  84. 

Blind,  institutional  and  state  care  for,  70. 

Blindness,  disability  from,  37;  causes  of,  39,66,70,93. 

Blue,  Rupert,  cited,  57. 

Blumer,  George,  data  by,  113n;6  estimates  by,  114. 

Boarding  houses,  inspection  of,  128. 

Boards  of  health ,  55;  increased  powers  and  reform  of, 
advocated,  56,128. 

Boies,  works  by,  cited,  88. 

Bok,  Edward,  95. 

Boston,  death  rate  in,  21;  death  rates  of  whites  and 
blacks  in,  22;  lowering  of  death  rate  in, 24;  small- 
pox epidemics  in,  30;  Nutrition  Research  Labo- 
ratory in,  64. 

Boston  Health  Education  League,  79. 

Bounties  for  married  couples,  51. 

Boys,  ill  health  among,  in  schools,  as  compared  with 
girls,  74;  importance  of  playgrounds  for,  77. 

Bracken,  cited,  57. 

Breadth  of  life,  defined,  33.    See  Life,  breadth  of. 

Brewer,  cited,  52. 

Bright's  disease,  increase  in  death  rate  from,  27,  32; 
relation  of  drinking  to,  88;  possible  prolongation 
of  life  by  elimination  of,  105. 

British  Sanitary  Institute,  64. 

Broncho-pneumonia,  responsibility  of,  for  shorten- 
ing of  life,  104. 

Brown,  Lawrason,  figures  by,  116. 

Bro\\Tilee,  J.,  cited,  30. 

Biicher,  Karl,  cited,  80. 

Building  laws,  municipal,  128. 

Burbank,  cited,  72. 

Burden,  W.  J.,  data  on  hook-worm  disease  by,  122. 

131 


132 


INDEX. 


Burk,  cited,  72. 

Burrage,  Severance,  work  by,  73. 
Byrnes,  Ronald  M.,  on  fecundity  of  Yale  graduates, 
54. 

C. 

Cancer,  increase  in  death  rate  from,  27,  32;  foothold 
gained  by,  through  lowered  vital  resistance,  39; 
possible  prolongation  of  life  by  elimination  of, 
105;  postponability  of  death  from,  109. 

Carpenter,  work  by,  84. 

Caspari,  work  on  vegetarianism  by,  43. 

Castle,  Charles  H.,  cited,  39;  estimates  by,  114. 

Census,  lile  tables  given  by,  19. 

Centenarians,  cases  of,  33,  112. 

Chadwick,  Edwin,  cited,  34;  quoted,  123. 

Chapin,  Charles  V.,  fresh-air  school  for  children  es- 
tablished by,  76;  estimates  by,  114;  quoted  on 
saving  of  infant  life  in  Providence,  121;  on  reduc- 
tion of  hook-worm  disease  in  Porto  Rico,  122. 

Chevreul,  example  of,  33. 

Chicago,  death  rate  in,  21;  study  of  backward  and 
defective  school  children  in,  73;  medical  inspec- 
tion of  schools  in,  76. 

Chicago  Society  of  Social  Hygiene,  79. 

Childhood,  laboratory  for  study  of,  72n.6 

Child-labor  committees,  national  and  State,  79. 

Child-labor  statistics,  38. 

Childlessness,  voluntary,  54. 

Children,  injury  rate  for  working,  38;  bounties 
offered  to  parents  of,  61;  average  number  of,  per 
family,  54;  importance  of  pure  milk  for,  57-58; 
regulation  of  labor  of,  59,  60,  127;  hygiene  of 
school  life  of,  72-79;  backward,  in  schools,  73-75; 
effects  on,  of  play  and  of  contest  among,  92;  of 
syphilitic  parent,  93;  importance  of  giving 
proper  models  for  imitation  to,  96-97;  contrast 
between  modem  care  for,  and  neglect  of  health 
of  adults,  98;  condition  of  parents  at  time  of 
conception  of,  101;  money  value  of,  117-118.  See 
Infants. 

Children's  Aid  Dental  Clinic,  New  York,  123. 

Children's  Aid  societies,  79. 

China,  national  degeneration  from  opium  in,  89; 
causes  of  backwardness  in,  96, 125. 

Chittenden,  Russell  H.,  experiments  by,  43;  cited, 
87. 

Cholera,  decrease  in,  resulting  from  discovery  of 
cause  of,  31. 

Christian  Science,  68. 

Churches,  health  movement  in,  71-72. 

Cincinnati,  death  rate  in,  21;  results  of  pure  milk 
supply  in,  58. 

Cities,  death  rates  in  American  and  European, 
21-22;  hygiene  of,  65-59,  128. 

Civilization,  unhygienic  side  of  inventions  of, 95-96. 

Clevelaad,  address  by,  cited,  94. 

Cleveland,  Ohio,  death  rate  in,  21. 

Clothing,  hygienic,  86, 129. 

Clouston,  "Hygiene  of  Mind"  by,  70. 

Coffee,  injurious  effect  of,  90. 

Colds,  danger  from  neglect  of,  39;  diseases  originat- 
ing in,  39;  preventability  of,  40;  resulting  from 
foul  air  in  railway  and  street  ears,  02;  impossi- 
ble in  an  outdoor  life,  85:  Benjamia  Franklin 
quoted  concerning,  85. 

Collier's  Weekly,  ground  taken  by,  against  objec- 
tionable advertising,  81. 

Committee  of  Fifty  on  the  liquor  problem,  88-89, 
120. 

Committee  of  One  Hundred  on  National  Health, 
66,  79,  81n.a 

Commons,  John  R.,  score  card  devised  by,  85. 

Congress  on  School  Hygiene,  72,  79. 

Connecticut,  prohibition  iu,  of  undesirable  mar- 
riages, 52. 

Connecticut  Society  of  Mental  Hygiene,  79. 

Conservation  of  vitality.    See  Vitality. 

Constipation,  38;  fatigue  resulting  from,  43. 

Consumption  resulting  from  dust-producing  occu- 
pations, 38. 

Copenhagen,  morbidity  among  school  children  in, 
74. 

Comaro,  L.,  example  of,  82. 

Cornell,  Walter,  on  backward  school  children,  74-75. 

Corsets,  tight,  86. 

Country,  disease  originating  in  the,  69. 

Country  Life,  Commission  on,  81, 

Cousins,  marriage  of,  50. 


Craig,  A.  L.,  76,  79. 

Crandall,  Floyd  M.,  cited,  29,  30. 

Crime,  alcoholism  and,  88-89;  the  result  of  m(Wbid 
conditions  and  habits,  124. 

Criminals,  restriction  of  alliances  of,  51-52, 129;  ster- 
ilization of,  52,  129. 

Crippling,  resulting  from  accidents,  37. 

Cronin,  on  backward  school  children,  73. 

D. 

Daggett,  W.  G.,  on  typhoid  as  a  rural  disease,  59. 

Dairies,  municipal  inspection  of,  128.  See  Milk 
supply. 

Dana,  Charles  L.,  quoted,  36,  97;  on  cost  of  care  of 
insane  and  feeble-minded,  120. 

Dana,  M.  G.,  work  by,  121n.  c 

Dangerous  trades,  37-38;  municipal  regulation  of, 
127. 

Darwin  family,  53-54. 

Deaf  mutes,  37;  institutions  for,  70. 

Death  rate,  reciprocal  relation  between  duration  of 
life  and,  19,  117;  defined,  19n<;;  "corrected" 
and  "crude,"  20;  in  various  regions,  20-21;  vir- 
ban  and  rural,  compared,  21;  variations  in,  ac- 
cording to  race,  social  status,  occupation,  etc., 
22-23;  decrease  in,  shown  by  historical  records, 
24-25;  lowering  of  infant,  increase  of  adult,  25- 
27,  98-99;  from  tuberculosis,  typhoid  fever, 
smallpox,  and  other  particular  diseases,  27-32; 
interrelation  of  infant,  and  purity  of  milk  sup- 
ply, 58;  a  high,  among  cliildren,  indicates  stunt- 
ing of  all  life,  99;  table  showing  comparative  re- 
sponsibility of  diseases  for,  104-106;  figures  of,  in 
United  States,  119. 

Deaths,  returns  of,  63-64;  causes  of,  by  diseases,  104- 
106;  so-called  causes  of,  v.  real  causes,  llO. 

Defectives,  institutional  care  for,  70. 

Degenerates,  prohibition  of  marriages  of,  51-52, 129; 
sterilization  of,  52, 129;  lajge  families  of,  54. 

Degeneration,  race,  100. 

Denmark,  duration  of  life  in,  16;  increase  in  length 
ofiifein,  18;  death  rate  of ,  20;  smallpox  and  vac- 
cination in,  30;  morbidity  among  school  chil- 
dren in,  74;  rate  of  lengthening  of  life  in,  102. 

Dental  clinics  in  schools,  123. 

Dentists,  preventive  methods  employed  by,  67. 

Department  stores,  filtration  of  air  in,  71. 

Devine,  Edward,  cited,  125. 

Diabetes,  increase  in  death  rate  from,  27,  32;  possi- 
ble prolongation  of  life  by  elimination  of,  105. 

Diarrhea,  percentage  of  death  rate  due  to,  104. 

Dickinson,  G.  L.,  cited,  91. 

Diet,  fatigue  due  to  improper,  42-44;  conclusions 
from  scientific  study  of,  86-88;  relation  of,  to  the 

Diploma  of  public  health  (D.  P.  H.),  65. 

Disease,  possibility  of  abolishiug  all  epidemic,  110. 

Diseases,  original  and  termiual,  110;  basis  of  esti- 
mates of  preventability  of,  113-114. 

District  of  Columbia,  expectation  of  life  in,  19;  te- 
duction  of  infant  mortality  in,  owing  to  public 
supervision  of  milk  supply,  58. 

Ditman,  Norman  E.,  cited,  27,  28,  29,  30,  31,  37,  63, 
64,  74,  88,  114, 121, 122;  quoted  on  insanity,  70. 

Doehring,  C.  F.  W.,  quoted,  37. 

Dogs,  experiments  with,  41,  65. 

Domestic  science,  87-88. 

Drakenberg,  centenarian,  112. 

Drug  addiction,  prevalence  of,  36,  88-90. 

Drugs,  decrease  in  use  of,  in  medical  practice,  66; 
state  regulation  of  sale  of,  127-128. 

Drummond,  W.  B.,  cited,  75. 

Dublin,  death  rate  in,  22, 102. 

Du  Bois,  cited,  92. 

Dudfield,  R.,  article  by,  64. 

Dugdale,  R.  L.,  study  of  the  Jukes  by,  53. 

Duration  of  life,  defined,  16n.6    See  Life,  length  of. 

Dust  in  air  of  houses,  84. 

Dust-producing  trades,  37-38;  need  of  municipal 
regulation  of,  127. 

E. 
Eager,  J.  M.,  cited,  70. 
Edison,  T.  A.,  example  of,  126. 
Eggs,  white  of,  in  diet,  42,  87. 
Ehrich,  Louis  R.,  cited,  54. 
Eight-hour  day,  the,  45-46, 60-61. 
Eliot,  Charles  W.,  cited  and  quoted,  64,  85;  stand 
taken  by,  against  use  of  alcohol,  90. 


INDEX. 


133 


Elliott,  E.  n.,  life  tables  by,  18,  107. 

Emanuel  Church  movement,  71 . 

Emerson,  Ralph  Waldo,  quoted,  48,  124. 

Employer's  liability  acts,  (11. 

Endocarditis,  responsibility  of  tonsilitis  for,  39;  pos- 
sible prolongation  of  life  by  elimination  of,  105. 

Endurance,  physical  and  mental,  40-41;  to  be  dis- 
tinguished from  strength,  41;  effect  of  tobacco 
on,  42;  improvement  in,  duo  to  thorough  mas- 
tication, 44,  8(J. 

Engcl,  on  cost  of  human  lives,  117. 

England,  duration  of  life  in,  16;  increase  in  length  of 
life  in.  18;  death  rate  of,  20;  tables  of  expectation 
of  life  ui,  27;  ravages  of  smallpox  In,  previous  to 
introduction  of  vaccination,  29;  attention  to 
school  hygiene  in,  72;  medical  inspection  of 
schools  in,  74,  70;  rate  of  lengthening  of  life  in, 
102,  103. 

Enteritis,  responsibility  of ,  for  shortening  of  life,  104. 

Environment,  results  of,  49;  hygiene  of  (air,  soil, 
dwelling,  clothing),  83-86;  man's  fitness  is  rela- 
tive to,  lOO-lOl. 

Epidemic  diseases,  causes  of  and  preventive  meas- 
ures against,  23-25,  28-32,  57,  59,  63,  67;  could  be 
abolished  within  fifty  years,  110. 

Epileptics,  marriage  of, prohibited,  52n.6  <; 

Eugenics,  science  of,  15,  49;  race  improvement 
through  heredity  the  subject-matter  of,  50;  gov- 
ernmental assistance  of,  51;  the  law  as  an  aid  in, 
51-54;  what  might  be  accomplished  by,  54;  liter- 
ature on,  54n<i;  question  of  science  of  hygiene 
conflicting  with,  97-101;  study  and  practice  of, 
advocated,  129. 

Europe,  death  rate  of,  by  sections,  20;  ravages  of 
smallpo.x:  in,  29. 

Example,  force  of,  96-97. 

Exercise,  importance  of,  91. 

Exertion,  physical,  capacity  for,  diminished  by 
alcohol  and  by  tobacco,  41-42;  importance  of, 
as  afiecting  capacity  to  resist  fatigue,  44. 

Exhaustion,  as  cause  of  pneumonia,  28. 

Expectation  of  life,  defined,  26n6;  average  lost,  by 
jarticular  diseases,  104-106;  method  of  calcu- 
lating, 113. 

Eye  strain  among  school  children,  74-75;  prevalence 
of,  and  evils  resulting  from,  75;  better  protection 
against,  advocated,  128. 

F. 

Factories,  improvements  on  hygienic  lines  in,  79-80, 

128. 
Famam,  Henry  W.,  89. 
Farr,  William,  life  tables  of,  17;  cited,  24, 119;  illness 

statistics  compiled  by,  34;  on  money  value  of 

human  lives,  118. 
Fatigue:  strength,  endurance,  and,  40-41;  alcohol 

and,  41-42;   tobacco  and,  42;  diet  and,  42-44; 

capacity  to  resist,  affected  by  physical  exertion, 

44;  due  to  long  hours  of  labor,  45-46;  importance 

of  preventing  undue,  47-48;  disregard  of  instinct 

of,  92;  economic  losses  from,  120. 
Fatigue  poisons,  41. 
Favill,  president  of  Chicago  Tuberculosis  Institute, 

79. 
Feeble-minded,  the,  37;  restriction  of  alliances  of, 

51-52;  money  cost  of,  annually,  120. 
Finkelnburg,  estimates  by,  17,  102. 
Fisher,  Irving,  cited,  17,  19,  34,  41,  43,  44,  86,  87,  116, 

118,  120,  124,  126. 
Fiske,  Haley,  cited,  23. 
Fitness,  relation  of,  to  environment,  100-101. 
Fletcher,  Horace,  example  of,  83;  as  exponent  of 

value  of  mastication  of  food,  86. 
Flexner,  Simon,  medical  achievement  of,  64. 
Flinders-Petri,  W.  M.,  cited,  97. 
Flint,  Joseph  M.,  114. 
Flourens's  law,  112. 
Food  preservatives,  82,  95. 
Foods,  question  of  the  best,  87. 
Forel,  cited,  93. 
Foresight,  importance  of,  126. 
France,  duration  of  life  in,  16;  increase  in  length  of 

life  in,  18;  death  rate  of,  20;  bounties  offered  in, 

to  increase  population,  51;  attention  to  school 

hygiene   in,    72;   experiment   in   education  of 

working  people  in  subject  of  hygiene  in,  79-81; 

degeneration  in,  from  use  of  absinthe,  89;  rate  of 

lengthening  of  life  in,  102. 
Frankfort-on-Main,  death  rate  in,  22. 


Franklin,  Benjamin,  on  colds,  85. 
Fresh-air  school  for  children,  76. 
Fromont,  L.  G.,  cited,  46. 


G. 


Galton,  Sir  Francis,  founder  of  science  of  eucenics 
15,  49,  50,  54. 

Garbage  removal,  municipal  and  legislative  regular 
lion  of,  50,  128. 

Gardens,  school,  77-78. 

Garlanda,  work  by,  72. 

Gamer,  James  W.,  cited,  62. 

Gasquet,  Abbot,  cited,  24. 

Gastritis,  39, 105. 

Gautier,  cited,  43. 

General  practice  of  physicians,  65;  progress  being 
made  in,  66. 

Geneva,  life  records  in,  17. 

Gennany,  death  rate  of,  20;  lowering  of  death  rates 
in  cities  of,  24;  attention  to  school  hygiene  in,  72; 
morbidity  among  school  children  in,  74;  cost  of 
school  dental  clinic  in,  123.    See  Prussia. 

Germ  origin  of  diseases,  67. 

Germ  theory,  application  of,  to  surgery,  65. 

Girls,  ill  health  among,  in  schools,  74. " 

Gladstone,  W.  E.,  example  of,  86. 

Glasgow,  death  rate  in,  affected  by  conditions,  22. 

Glover,  J.  W.,  cited,  108n.6 

Goler,  George  W.,  quoted,  57-58,  72. 

Gonorrhea,  invalidity  from,  35-36;  serious  results 
of,  93-94. 

Gonorrheal  contamination,  decrease  in,  due  to  anti- 
sepsis, 60. 

Gore,  John  K.,  cited,  24. 

Gorgas,  W.  C,  cited,  25,  31;  quoted  on  practical 
extinction  of  malaria  in  Habana,  32. 

Gouge,  H.  Dillon,  figures  by,  89. 

Gould,  George  M.,  quoted  and  cited,  75,  125;  esti- 
mate of,  on  loss  from  preventable  sickness  and 
death, 120. 

Graham,  Edward  E.,  cited,  25,  97. 

Grant,  Percy  Stickney,  quoted,  78. 

Graves,  cited,  55. 

Great  Britain,  morbidity  among  school  children  in, 
74;  death  rates  in,  99;  worth  of  capitalized  human 
labor  in,  117.    See  England. 

Greeks,  athletics  among  the  ancient,  91;  racial  de- 
generation among,  caused  by  malaria,  99-100. 

Grenfell,  Labrador  missionary,  quoted,  80. 

Grip,  caused  by  foul  air  in  railway  and  street  cars, 
62. 

Guinea  pigs,  effects  of  bad  air  on,  85. 

Gulick,  Luther  H.,  quoted  and  cited,  40,  74,  75, 120. 
123. 

Gymnasia,  establishment  of,  15,  78. 

H. 

Habana,  vital  records  of,  25;  smallpox  and  vaccina- 
tion in,  30;  decrease  in  death  rate  from  yellow 
fever  in,  30-31;  practical  extinction  of  malaria 
in,  32. 

Hague,  The,  death  rate  in,  22. 

Hall,  (J.  Stanley,  cited,  67,  92. 

Hamburg,  lowering  of  typhoid-fever  death  rate  in. 
28. 

Harrington,  Charles,  cited,  57. 

Hartford,  death  rate  in,  21. 

Hawaiians,  an  example  of  race  extinction  due  to 
immoraUty,  101. 

Haydoelr,  cited,  lOSn.s 

Hayward,  calculations  of,  108n,b  113. 

Hazen'3  theorem,  35, 110, 121. 

Headache,  39,  75,  86. 

Health,  e.xpressions  of  great  men  concerning,  48; 
viewed  as  wealth,  124;  morality  and,  correlative 
or  interchangeable  terms,  125. 

Health  day,  proposed,  78. 

Health  officers,  public,  55-56,  65,  128. 

Health  week,  78. 

Heart  disease,  increase  in  death  rate  from,  27,  32;^ 
cause  of  increase  of,  98;  possible  prolongation  of 
life  by  elimination  of,  104,  105. 

Henderson,  C.  R.,  95. 

Heredity,  human  vitality  dependent  on,  49. 

Herter,  C.  A.,  cited,  42,  87;  quoted,  78. 

Higgins,  Hubert,  46  n.a;  quoted  and  cited,  79-80, 86. 

Hirt,  statistics  by,  38. 


84369— No.  30—09- 


-10 


134 


INDEX. 


Hoffman,  Frederick  L.,  cited,  23,  28,  32,  37,  101; 
quoted,  26. 

Hohenzollern  family,  53. 

Holmes,  G.  K.,  cited,  87. 

Holt,  L.  Emmett,  estimates  by,  113  n.^,  114. 

Home  economics,  science  of,  71,  88. 

Homes  Commission,  81. 

Hook-worm  disease,  35,  60;  shortening  of  life  by,  110; 
preventability  of,  113  n.b;  money  losses  from, 
122. 

Hospitals,  establishment  of  contagious,  70. 

House  fly,  danger  of  infection  from  typhoid  from, 
29,  57. 

Houses,  air  in,  84-85. 

Howard,  L.  O.,  29;  cited,  32,  35,  57;  on  prevalence 
of  malaria  in  United  States,  3-5;  report  by, 
!  quoted,  99;  estimates  by,  114:  on  cost  of  malaria, 
annually,  120. 

Howe,  Charles  S.,  125  n.d. 

Huber,  John,  cited,  34,  88. 

Huddersfield,  lowering  of  infant  mortality  rate  in, 
121. 

Humboldt,  Alexander  von,  33,  41,  82,  83. 

Humphreys,  cited,  30,  36. 

Hungary,  death  rate  from  smallpox  in,  29. 

Hunniston,  quoted,  94  n.6. 

Hurty,  J.  N.,  quoted,  52. 

Hydrotherapy,  66,  90,  96. 

Hygiene,  classification  of,  in  three  groups:  public, 
semipublic,  and  personal,  55;  division  of  pubUc, 
into  municipal,  state,  and  federal,  56;  municipal 
ordinances  along  line  of  public,  56-59;  municipal 
should  be  supplemented  by  state,  59;  state, 
comprises  regulation  of  woman  and  child  labor, 
length  of  working  day,  industrial  accidents,  and 
tenements,  59^1; federal,  61-64;  semipublic,  de- 
fined, 64;  use  of,  in  the  medical  profession,  65-70; 
displacement  of  medicines  and  serums  by,  66; 
institutional,  70-72;  mental,  70-71;  of  school  life, 
72-79;  organizations  devoted  to  promoting,  79- 
81;  importance  of  personal,  82;  three  branches  of 
personal:  hygiene  of  environment,  of  nutrition, 
and  of  activity,  83;  of  environment,  84-86;  of 
nutrition,  86-88;  avoidance  of  poisons  the  first 
rule  of,  88;  activity,  90-92;  sex, '92-95;  value  of 
imitation  to  progress  in,  96;  question  of  science 
of,  conflicting  with  science  of  eugenics,  97-101; 
eflectof,onman's  working  period,  109;  national, 
state,  and  municipal  measures  to  ha  taken 
tending  toward,  126-128;  importance  of  observ- 
ance of  personal,  and  of  study  and  practice  of 
eugenics,  129. 


Idiots,  sterilization  of,  52, 129. 

Igorots,  teeth  of,  95  n.a 

Illness,  statistics  of,  34;  money  cost  of,  119-120. 
See  Invalidity. 

Imitation,  value  of  power  of,  to  hygienic  progress, 
96;  force  of,  among  children,  96-97. 

Im-migrants,  money  value  of,  118. 

Immigration,  death  rate  in  America  modified  by,  19. 

Immorality,  race  extinction  resulting  from,  101. 

India,  duration  of  life  in,  10;  no  increase  in  length 
of  life  in,  19, 102;  death  rate  of,  20. 

Indiana,  prohibition  in,  of  undesirable  marriages, 
52;  sterilization  of  criminals  and  defectives  in, 
52;  example  of,  should  be  followed,  129. 

Indians,  an  example  of  race  extinction  due  to  im- 
morality, 101. 

Industrial  insurance,  statistics  from,  23. 

Infants,  lowering  of  death  rate  among,  25-27;  re- 
duction in  mortality  of,  by  pure-milk  supply, 
58,  121;  question  of  benefit  of  prolonging  lives 
of,  97-98;  high  mortality  rate  among,  tends  to 
stunt  all  life,  99. 

Information,  governmental  dissemination  of,  62, 127. 

Insane,  prolongation  of  lives  of  the,  52-53, 97;  money 
cost  of^  annually,  120. 

Insanity,  mcrease  of,  36,  97;  checking  of,  70;  rela- 
tion of  drinking  to,  88;  resulting  from  venereal 
diseases,  93. 

Insect-bome  diseases,  57,  67;  money  cost  of,  120; 
measures  against,  should  be  taken  by  munici- 
palities, 128. 

Institutional  hygiene,  70-72. 


Insurance  companies,  influence  to  be  exercised  by, 
80,  129;  statistics  of,  regarding  drinking,  89; 
advantages  to,  of  actively  joining  in  public- 
health  movement,  123. 

International  Congress  on  School  Hygiene,  72,  79. 

Invalidity,  universality  of,  33;  loss  of  time  from, 
33-34;  statistics  of,  34;  from  minor  aihnents, 
38-39;  money  cost  of,  119-120. 

Invention,  part  played  by,  in  industrial  progress, 
125. 

loteyko,  J.,  cited,  43. 

Ishmael  famUy,  53. 

Italy,  duration  of  life  in,  16;  death  rate  of,  20;  atten- 
tion to  school  hygiene  in,  72. 


Jacobi,  A.,  cited,  61-69. 

Japan,   death  rate  of,  20;  physical  training  and 

hygiene  in,  51;  efficiency  of  hygiene  of,  shown 

in  army,  63;  principal  causes  of  progress  in, 

96, 125. 
Jarvis,  Edward,  cited,  17,  34,  109,  123;  quoted,  49. 
Jaundice,  possible  significance  of,  39. 
Jevons,  W.  Stanley,  cited,  60. 
Jessen,  on  cost  of  school  dental  clinic  in  Germany, 

123. 
Johnson,  G.  Woodrufl,  cited,  74. 
Jordan,  David  Starr,  cited,  bin.d 
Jordan,  Edwin  O.,  114. 
Juke  family,  53. 

K. 

Kant,  example  of,  82. 

Kastle,  Jos.  H.,  cited,  29. 

Keating,  "Mother  and  Child"  by,  73. 

Keller,  Albert  G.,  "Eugenics"  by,  54  n.<J 

Kellogg,  J.  H.,  cited,  90,  114,  120. 

Kipiani,  Varia,  cited,  43. 

Kirkpatrick,  cited,  75. 

Kober,  George  M.,  cited,  17,  24,  29,  38,  58,  59;  on 

annual  cost  of  typhoid,  120. 
Koch,  extermination  of  diphtheria  in  Trier  by,  113 

n.b 
Kraeplin,  cited,  72. 
Krupp,  example  of,  126. 
Kuropatkin,  cited,  100. 


Ladies'  Home  Journal,  stand  taken  against  objec- 
tionable advertising  bv,  81. 

Lambert,  T.  S.,  quoted,  121. 

Lankester,  E.  R.,  cited,  52,  111;  quoted,  110. 

Lausanne,  morbidity  among-schoolgirls  in,  74. 

Lawrence,  Mass.,  loVeruig  of  typhoid  fever  death 
rate  in,  28. 

I/Can  meat,  excessive  use  of,  in  diet,  42-43,  87,  91. 

Leprosv,  isolation  treatment  and  disappearance  of, 
70." 

Levasseur,  E.,  cited,  22. 

Life,  money  valuation  of  human,  117-120;  conser- 
vation of.     See  under  Vitality. 

Life,  breadth  of:  Invalidity  the  opponent  of,  33-34; 
to  be  gained  negatively  by  preventing  disease, 
40;  positively,  by  cultivation  of  vitality,  47-48. 

Life,  length  of :  In  leading  countries,  16;  at  different 
times,  17-19;  reciprocal  relation  between  death 
rate  and  19, 117;  rate  of  increase  in,  per  centnrv, 
102-103;  'the  normal,  111-112. 

Life,  prolongation  of:  Table  showing  the  possible, 
104-106;  diagram  showing  effect  of,  at  different 
ages,  107-109;  fifteen  years  a  safe  minimum  esti- 
mate of  possible,  109-111;  valuable  results  from, 
111. 

Light,  benefits  from,  86. 

Lindsey,  Ben.  B.,  90. 

Liquor  problem,  120.    See  Alcohol. 

Liquor  traffic,  control  of,  59. 

Liver  disorders,  increase  in  death  rate  from,  27. 

Locomotor  ataxia,  sj^^hilis  may  lead  to,  93;  possible 
prolongation  of  life  by  elimination  of,  105. 

Lodging  houses,  inspection  of,  128. 

Lombard,  Warren  P.,  quoted,  42. 

London,  historical  records  of  mortality  in,  24;  de- 
fective vision  of  school  children  in,  74-75. 


INDEX, 


135 


LovejOY,  Owen  R.,  statistics  liy,  38. 
Lnmbfigo,  possible  significance  of,  39. 
Lumsclen,  L.  L.,  cited,  29. 

M. 

MeComb,  Samuel,  71. 

McCormack,  J.  N.,  quoted,  56. 

McCuiloch,  Oscar  C,  cited,  53. 

Macdonnell,  W.  R.,  cited,  30. 

McCJee,  cited,  55. 

MacNntt,  Pcott,  35,  121. 

McVail,  John  C,  data  on  preventability  by,  llSn.ft 

Malaria,  decline  in  death  rate  from,  31-32;  preventa- 
bility of,  as  shown  at  llabana,  32;  invalidity 
from,  35;  racial  degeneration  caused  among 
Greeks  by,  99-100;  possible  prolongation  of  life 
by  elimination  of,  105;  shortening  of  life  by,  110; 
rrionev  cost  of,  annuallv,  120. 

Mallet,  cited,  17. 

Marine-Hospital  Service,  61,  05. 

Marriages,  choice  in,  49-50;  suitable,  50;  restriction 
placed  on,  of  criminals  and  defectives,  51-52. 
See  Eugenics. 

Massachusetts,  duration  of  life  in,  10;  life  tables  for, 
18,  19,  107-109,  113,  117;  death  rate  in,  21;  com- 
parison of  urban  and  rural  death  rates  in,  21; 
death  rates  in,  by  age,  26;  table  of  expectation 
of  life  in,  26;  insanity  in,  36;  medical  inspection 
of  schools  in,  75;  percentages  of  crime,  pauper- 
ism, and  insanity  in,  due  to  alcohol,  89;  rate  of 
lengthening  of  life  in,  102,  103. 

Mastication,  value  of,  44,  SO. 

Maxwell,  William  II.,  on  school  gardens,  77-78. 

May,  Charles  H.,  quoted,  93n.<; 

Mayo,  William  J.,  quoted  on  X-rays  and  suture  of 
blood  vessels,  65. 

Mayo-Smith,  R.,  cited,  17,  34,  90;  on  money  value 
of  himian  lives,  117-118. 

Meat  eating,  42-43,  87,  94. 

Meat  inspection,  62,  127. 

Medical  inspection  of  schools,  72-76,  123,  128. 

Medical  schools,  number  and  importance  of,  64-65; 
preventive  practice  and  training  of  health  offi- 
cers in,  128. 

Medicine,  revolution  in  practice  of,  15,  64ff;  sup- 
planting of,  by  hygiene,  66. 

Meech,  Levi  W.,  life  "tables  by,  IS. 

Memorial  Institute  for  Infectious  Diseases,  15,  64. 

Meningitis,  serum  for  treatment  of,  64;  responsibil- 
ity of,  for  shortening  of  life,  104;  basis  of  esti- 
mates of  preventability  of,  113n.i) 

Messenger,  Hiram  J.,  pamphlet  by,  34n;a  quoted, 
123. 

Metchnikoff,  Elie,  cited  and  quoted,  14,  27, 33, 55, 60, 
67,  82,  83,  88,  109,  111,  112, 125;  originates'  'sour- 
milk  craze,"  96. 

Meyer,  Adolph,  cited,  76. 

Michigan,  death  rate  in,  21;  comparison  of  urban 
and  rural  death  rates  in,  21;  prohibition  in,  of 
undesirable  marriages,  52. 

Midwifery,  antiseptic  surgery  and,  66. 

Milk-borne  epidemics,  58. 

Milk  supply,  improvement  of,  lowers  death  rate 
from  typhoid  fever,  28;  infant  diseases  eradi- 
cated by  a  pure,  32;  public  supervision  of,  57; 
prevention  of  children's  tuberculosis  by  secur- 
ing a  pure,  58;  importance  of  a  pure,  107;  meas- 
ures regarding,  to  be  taken  by  municipalities, 
128. 

Milnes,  cited,  30. 

Mind,  hygiene  of  the,  70-71. 

Miners,  accidents  among,  37. 

Minnesota,  vaccination  in,  57. 

Minor  ailments,  unsuspected  importance  of,  38-39; 
loss  of  time  from,  39;  preventability  of,  40. 

Mitchell,  John,  cited,  37. 

Mommsen,  example  of,  41. 

Money  value,  of  human  lives,  117-119;  of  elimination 
of  invalidity,  119-120. 

Montclair,  public  supervision  of  milk  supply  at,  57. 

Morality,  correlative  with  health,  125. 

Morbidity,  among  school  children,  74;  increases 
with  age  in  geometric  progression,  119. 

Morrow,  Prince  A.,  on  invalidity  from  social  dis- 
eases, 35,  93,  94;  on  syphilitics  in  United  States, 
35;  tribute  to  efforts  of,  95;  estimates  by,  114. 

Morse,  J.  F.,  cited,  39. 

Mortality.    See  Death  rate. 

Moscow,  death  rate  in,  22. 


Mosq\iito,  yellow  fever  transmitted  by.  30,  121-122; 

malaria  transmitted  by,  31,  57,  120. 
Mosso,  cited,  41. 
Mothers'  clubs,  71. 
Muir,  John,  quoted,  85. 
Munich,  lowering  of  death  rate  in,  24,  28. 
Municipal  hygiene,  55-59, 128. 
Music  in  factories,  80. 

N. 

National  Association  for  Study  and  Prevention  of 
Tuberculosis,  79. 

Navy  Department  statistics  on  venereal  diseases,  'M'l. 

Negro,  as  an  example  of  race  extinction  duo  to  im- 
morality, 101. 

Negroes,  death  rate  of,  22;  high  death  rate  from 
tuberculosis  among,  28. 

Neisser,  cited,  30. 

Nephritis,  increase  in  death  rate  from,  27;  possible 
prolongation  of  life  by  elimination  of,  105. 

Ner\'ous  diseases,  cause  of  increase  of,  98. 

Ner\'ous  overstrain  in  schools,  71',  70-77. 

Nervous  prostration,  outdoor  cure  for,  40;  caused  b-y 
sedentary  occupation,  91. 

Neurasthenia,  results  of,  39:  fresh-air  treatment  for, 
67. 

New  Haven,  death  rate  in,  21. 

New  Jersey,  expectation  of  life  in,  19;  comparison  of 
urban  and  rural  death  rates  in,  21. 

New  London,  death  rate  in,  21. 

Newsholme,  Arthur,  cited,  22,  r8,  31,  70. 

Newspapers,  powers  for  good  and  evil  of,  81. 

Newton,  R.  C,  cited,  73. 

New  York  City,  expectation  of  life  in,  19;  death  rate 
in,  21;  lowering  of  death  rate  in,  24;  statistics  of 
physical  defects  of  school  children  in,  74;  medical 
inspection  of  schools  in,  75;  water  of  roof  tanks 
in,  86;  decrease  of  mortality  from  diphtheria  in, 
113nf>;  Children's  Aid  Dental  Clinic  in,  123. 

New  York  State,  death  rate  in,  21;  commission  on 
the  bhnd  in,  70. 

Nicholson,  J.  S. ,  on  capitalized  value  of  human  labor 
in  Great  Britain,  117. 

Noises,  lessening  of,  57, 128. 

Nutrition,  hygiene  of,  83,  86-88. 

Nutrition  Research  Laboratory,  64. 

O. 

Occupation,  dependence  of  death  rate  on,  23;  ill- 
health  resulting  from,  39,  91,  96. 

Ogle,  life  tables  of,  17, 18. 

Old  age,  postponabihty  of,  109, 111-112. 

Old-age  pensions.  111. 

One-child  sterility,  94. 

Opium,  degeneration  in  China  from,  89. 

Oppenheim,  cited,  72. 

Optic-nerve  blindness,  minor  ailments  leading  to, 
39. 

Organizations  working  for  improvement  of  hygienic 
conditions,  79. 

Osborne,  Oliver  T.,  114. 

Osier,  cited,  67,  88;  on  loss  from  lack  of  medical 
supervision  of  schools,  73. 

O'Shea,  M.  V..  cited,  72, 75. 

Ottofy,  cited,  95. 

Outdoor  sleeping,  value  of,  67,82,84. 

Outlook,  The,  ground  taken  by,  against  objection- 
able advertising,  81. 

Overeating,  fatigue  from,  42-43,87;  colds  caused  by, 
85. 

Oxygen,  artificial  administration  of,  44. 

Oysters,  dangers  of,  87. 


Panama,  decrease  in  death  rate  from  yellow  fever 
at,  31. 

Panama  Canal  Zone  vital  records,  25. 

Paralysis,  disability  from,  37;  syphilis  may  lead  to, 
93;  possible  prolongation  of  life  by  elimination 
of,  105. 

Parents,  results  of  disease  in,  93;  force  of  example 
of,  97;  effects  of  condition  of,  at  time  of  concep- 
tion of  children,  101. 

Paresis,  increase  in  death  rate  from,  27.  * 

Pareto,  cited,  118n,d  124. 

Paris,  death  rate  in,  afiected  by  conditions,  22. 


136 


INDEX. 


Pasteur,  Louis,  quoted,  14. 

Pasteur  Institute,  work  of,  G4. 

Pasteurized  millv,  58. 

Patten,  Simon  N.,  cited,  92,99. 

Paupers,  restriction  of  alliances  of,  51-52, 129. 

Pearson,  -Karl,  15, 49;  cited,  30,  54n.d 

Periodicals,  influence  of,  81. 

Peritonitis,  may  originate  in  tonsilitis,  39;  possible 
prolongation  of  life  by  elimination  of,  105. 

Personal  hygiene,  82-97. 

Pettenkofer,  cited,  34. 

Phelps,  E.  B.,  cited,  25,  97. 

Philadelphia,  death  rate  in,  21;  economic  loss  to, 
from  smallpox  epidemic,  122. 

Phipps  fund,  the,  70. 

Physical  education  of  children,  78. 

Physicians,  training  of,  as  public  health  oflicers,  55- 
56,65,128;  private  practice  of,  65;  division  of 
private  practice  of,  into  surgery  and  general 
practice,  65;  progress  being  made  in  surgery, 
65-66;  in  general  practice,  66-67;  preventive 
measures  supplanting  curative  in  practice  of, 
66-67;  quacks  r.,  67-68;  standards  necessary  for, 
67,69;  number  of,  in  United  States,  69. 

Play  for  children  and  adults,  83,92. 

Playgrounds  for  children,  77, 128. 

Pneumonia,  high  death  rate  from,  in  United  States, 
28;  resulting  from  dust-producing  occupations, 
38;  fresh-air  treatment  for,  67;  fatal  to  drunk- 
ards, 88n  6;  more  apt  to  attack  the  strong  than 
the  weak,  100n«;  responsibility  of,  for  short- 
ening of  life,  105. 

Poisonous  trades,  37-38;  regulations  concerning, 
127. 

Poisons,  fatigue,  41, 92;  in  air  from  wall  paper  and 
plaster,  84. 

Porto  Rico,  reduction  of  hook-worm  disease  in, 
35, 122. 

Poverty,  relation  of,  to  mortality  rate,  22-23;  alco- 
holism and,  89;  disease  plays  leading  role  in, 
124;  lack  of  forethought  one  cause  of,  126. 

Powers,  Le  Grand,  estimates  by,  119n.o 

Preventability  of  disease,  estimates  of,  103-107; 
basis  of  estimates  of,  113-114;  ratios  of,  by  ages, 
116;  savings  possible  by,  120. 

Preventable,  meaning  of  word,  114-115. 

Preventive  medical  practice,  15,31,  66-67,128;  at- 
tention paid  to  minor  ailments  by,  39. 

Price,  quoted,  94n.6 

Prolongation  of  life.    See  Life,  prolongation  of. 

Protein,  fatigue  from  decomposition  of,  42-43,  87; 
decreased  by  mastication,  44,  86. 

Providence,  fresh-air  school  in,  for  tuberculous 
children,  76. 

Prussia,  duration  of  life  in,  16;  increase  in  length 
of  life  in,  18;  effect  of  vaccination  on  smallpox 
in,  29;  rate  of  lengthening  of  life  in,  102. 

Public  health,  diploma  in,  65. 

Public  Health  and  Marine-Hospital  Service,  61,  65. 

Public  health  ofTicer,  profession  of,  55-56,  65,  128. 

Pure-food  laws,  62,  127. 

Putnam,  Helen,  cited,  78. 

Q. 

Quacks,  medical,  67-68;  advertising  of,  81. 

{Quarantine,  smallpox  epidemics  prevented  by,  57; 
included  in  federal  hygiene,  61;  development  of 
our  national,  62;  effects  of,  in  the  case  of  tuber- 
culosis and  leprosy,  70. 

Quetelet,  cited,  20. 

R. 

Race,  variations  of  death  rate  according  to,  22.     ' 

Race  degeneration,  decay  of  foresight  one  of  first 
symptoms  of,  126. 

Hace  extinction,  resulting  from  immoralitj^  101. 

Race  improvement,  49-51. 

Race  suicide,  54. 

Race  weakening  by  use  of  hygienic  measures,  ques- 
tion of,  97-98. 

Rae,  John,  cited,  126. 

Railway  accidents,  37,  4G. 

Railway  trains,  hygienic  measures  needed  regard- 
ing, 62,  84. 

Rapists,  sterilization  of,  .52, 129. 

Rats,  disease  transmitted  by,  57, 67;  measures  taken 
against  infection  from,  in  San  Francisco,  122. 


Recreation,  necessity  of,  92. 

Red  Cross  Society,  79. 

Reed,  AValter,  121. 

Registration  of  births  and  deaths,  63-64,  127. 

Research  institutions,  15,  64,  128. 

Richards,  Ellen  H.,  quoted,  75,  120;  cited,  84,  120. 

Rivers,  W.  H.  R.,  cited,  41. 

Rochester,  pure  milk  question  at,  58. 

Rockefeller  Institute  lor  Medical  Research,  15,  G4. 

Roosevelt,  Theodore,  quoted,  14,  51;  referred  to,  64. 

Rosenau,  M.  J.,  cited,  29. 

Ross,  Ronald,  quoted,  99-100. 

Rowe,  cited,  75. 

Rubinow,  I.  M.,  cited,  23. 

Rugs !).  carpets,  84. 

Russia,  effect  of  varying  conditions  on  death  rate 

in,  23;  high  mortality  rate  among  infants  in, 

and  also  among  adults,  99. 


Sage  fund  for  study  of  diseases  of  old  age,  15. 

St.  Petersburg,  death  rate  in,  22. 

Saleeby,  cited,  92. 

Sanatoria,  oflfice  of,  71. 

Sanbom,  F.  B.,  quoted,  37,  53. 

San  Francisco,  measures  taken  in,  against  infection 
from  rodents,  122. 

Schofield,  A.  T.,  cited,  67,  68,  92. 

School  buildings,  73,  78-79. 

School  gardens,  77. 

School  hygiene,  72-79. 

Schools,  physical  education  in,  15,  78;  necessity  of 
medical  inspection  of,  72-76,  128;  nervous  over- 
strain in,  76-77;  cost  of  medical  inspection  of, 
and  money  value  of,  123. 

Schwartz,  Hermann,  article  by,  72n.6 

Scotland,  illness  statistics  of,  34;  attention  to  school 
hygiene  in,  72. 

Scott,  cited,  75.  ■ 

Scurvy,  preventive  measures  against,  31. 

Seaman,  L.  L.,  cited,  63. 

Seaver,.on  effects  of  tobacco,  90. 

Sedgwick,  W.  T.,  cited  and  quoted,  35,  121;  on 
"Hazen's  theorem,"  110. 

Serum  therapy,  66. 

Serum  treatment  of  meningitis,  113n.6 

Sewage  disposal,  57;  legislation  needed  regarding, 
128. 

Sewers,  closing  of,  56. 

Sex  hygiene,  92-95. 

Shadwell,  cited,  125. 

Shaler,  N.  S.,  cited.  111. 

Shattuck,  Lemuel,  cited,  22,  24,  30. 

Shaw,  cited,  73. 

Shoes,  tight,  86. 

Sick  headache,  39,  75. 

Sickness,  money  cost  of,  119-120.    Sec  Invalidity. 

Sidis,  cited,  92. 

Slaughterhouses,  inspection  of,  58, 128. 

Sleep,  importance  of,  83,  92. 

Sleeping  rooms,  84. 

Smallpox,  lowering  in  death  rate  from,  due  to  vacci- 
nation, 29;  effect  of  public  hygiene  on,  57;  possi- 
ble prolongation  of  life  by  elimination  of,  105; 
basis  of  estimates  of  preventability  of,  llSn;* 
money  losses  from,  122. 

Smith,  Southward,  cited,  17. 

Smoke  nuisance,  the,  56, 128. 

Smoking,  evil  effects  of.  42,  90. 

Smoking  cars,  dangers  from,  and  remedy,  62. 

Social  SL>cretaries,  79. 

Social  diseases,  35-36,  92-95. 

Social  status  and  death  rate,  22. 

Society  for  Sanitary  and  Moral  Prophylaxis,  79. 

Soldiers,  experiments  with,  43. 

Solvay  Process  Company,  eight-hour  shifts  at,  and 
results,  46. 

Sour  milk,  avoidance  of  auto-intoxication  by  use 
of,  87. 

"  Sour  milk  craze,"  96. 

South  Carolina,  annual  cost  to,  of  hook-worm  dis- 
ease, 122. 

Spargo,  John,  cited,  60. 

Spinal  curvature,  39,  75,  91,  96. 

Spitting,  ordinances  against,  56. 128. 

Steele,  Harry  M.,  114. 

Sterihzation  of  criminals  and  defectives,  52, 101, 129. 

Sterilizing  effects  of  veneral  diseases,  35-36,  93-94. 


INDEX. 


137 


stiles,  Charles  W.,  cited,  50,  CO;  suggestion  of  an 
annual  liealth  week  by,  78;  on  prevontability  of 
hook-worm  disease,  113n;''  authority  of ,  on  rav- 
ages of  hook-worm  disease,  122. 

Stockholm,  morbidity  among  schoolgirls  in,  74. 

Stoddard,  C.  F., cited,  89. 

Streets,  cleaning  of,  57, 128. 

Strength,  endurance  distinguished  from,  41. 

Sumner,  Helen  L.,  cited,  GO,  SO. 

Sunshine,  benefit  of,  80. 

Sunshine  societies,  79. 

Surgery,  a  division  of  private  practice,  05;  antisep- 
tic'and  aseptic,  65;  useof  X  rays  andof  suturcof 
blood  vessels  in,  05;  table  showing  advance  in,  06. 

Survivorship  table,  107. 

Suture  of  blood  vessels,  05. 

Swain,  M.  L.,114. 

Sweden,  duration  of  life  in,  16;  increase  in  length  of 
life  in,  IS;  death  rate  of,  20;  morbidity  among 
school  children  in,  74;  rate  of  lengthening  of  life 
in,  102. 

Sweeping,  improvement  in  methods  of,  84. 

Swift,  cited, 75. 

Swimmers,  artificial  administration  of  oxygen  to, 
44. 

Switzerland,  death  rate  from  smallpox  in.  29;  atten- 
tion to  school  hygiene  in,  72;  leads  the  nations 
in  caring  for  physical  welfare  of  children,  76. 

Sykes,  cited,  84. 

Syphilis,  invalidity  from,  35-3'"-;  serious  results  of, 
92-93. 

T. 

Tanner,  cited,  75. 

Tea,  injurious  eflect  of,  90. 

Teeth,  of  school  children,  73,  74,  123;  ill  effects  of 
civilization  on,  95;  of  Igorots  and  of  civilized 
Filipinos,  95  n.a 

Temperance  demanded  of  employees,  80. 

Temperance  organizations,  79. 

Tenement-house  legislation,  61, 128. 

Terminal  diseases,  110. 

Tobacco,  fatigue  from  use  of,  42  90;  treatment  of 
subject  in  school  physiologies,  78. 

"Tobacco  heart,"  90. 

Tolman,  W.  H.,32. 

Tousilitis,  origin  and  effects  of,  39;  possible  prolon- 
gation of  life  bv  elimination  of,  104. 

Towmsend,  J.  H.,  114. 

Transportation,  hygiene  of,  61-62. 

Travis,  cited,  75. 

Tredgold,  figures  by,  54. 

Trier,  extermination  of  diphtheria  in,  113  n.*. 

Tuberculosis,  resulting  from  dusty  trades,  23;  death 
rate  from,  in  United  States,  27-28,  34;  causes  of 
fall  in  mortality  from,  31;  relation  of  typhoid 
fever  and  book-worm  disease  to,  35:  outdoor 
cure  for,  40, 67;  reduction  of,  by  introduction  of 
closed  sewers,  56;  among  children,  preventable 
by  use  of  pure  milk,  58;  inexactness  of  statistics 
regarding,  63;  decrease  of,  due  to  hospital  isola- 
tion, 70;  fresh-air  school  for  children  suffering 
from,  70;  induced  even  in  so-called  "ventilated 
house,''  95;  possible  prolongation  of  life  by  elim- 
ination of,  105;  malaria  and  hook-worm  "disease 
predispose  to,  110;  expectation  of  life  for  persons 
saved  from,  110;  money  cost  of,  120. 

Turner,  F.  M.,  cited,  30. 

Tyler,  cited,  72. 

Typesetters,  experiments  with,  in  effects  of  alcohol, 
42. 

Typhoid  fever,  fall  in  death  rate  from,  and  causes, 
28;  due  to  impure  water,  28-29;  house  fly  a 
source  of  danger  of  infection  from,  29,  57;  inval- 
idity from,  and  Hazen's  theorem,  35,  110,  121; 
effect  on,  of  supplanting  of  horses  by  automo- 
biles, 57;  in  origin  largely  a  rural  disease,  59; 
losses  from,  in  British  army  in  South  Africa,  63; 
more  apt  to  attack  the  strong  than  the  weak, 
100  n.o;  possible  prolongation  of  life  by  elimina- 
tion of,  104;  basis  of  estimates  of  preventability 
of,  113  n.b;  money  cost  of,  annually,  120;  cost  of, 
to  city  of  Pittsburg,  121. 

"Typhoid  fly,"  the,  29,  57. 


U. 

Ulpian,  life  table  of,  17. 

United  States,  need  of  vital  statistics  in,  18, 120-127; 
relation  between  death  rate  and  duration  of  life 
in,  19-20;  death  rate  of,  20;  lowering  of  death 
rates  in  cities  of,  24;  excessive  death  rate  from 
tuberculosis  in,  27-28;  illness  statistics  of,  34; 
insanity  in,  36.    See  Ma-ssachusetts. 

Universities,  investigations  supported  by,  15; 
courses  in  hygiene  in,  64,  128. 

University  settlements,  79. 

V. 

Vaccination,  death  rate  from  smallpox  lowered  by, 
29;  present  outcry  against  but  undoubted  effi- 
cacy of,  30,  57;  individual  option  as  to,  in  some 
localities,  57;  origin  of  the  misguided  movement 
against,  68. 

Vaccine,  municipal  distribution  and  administra- 
tion of,  58. 

Van  Cise,  Jool  G.,  cited,  89. 

Vegetai-ianism,  43,  87. 

Venereal  diseases,  prevalence,  effects,  and  prevent- 
ability of,  35-36,  92-95,  110;  possible  prolonga- 
tion of  life,  by  elimination  of,  104. 

Ventilation,  importance  of,  84-86.    See  Air. 

Vermont,  death  rate  in,  21. 

Vienna,  decrease  in  death  rate  of,  24. 

Violence,  as  a  cause  of  shortening  of  life,  105.  See 
Accidents. 

Visiting  Nurses'  Association,  79. 

Vitality,  conservation  of,  through  heredity  and 
environment,  49-50;  to  be  considered  the  first 
essential  in  ideal  man  or  woman,  50-51 ;  conserva- 
tion of  through  public,  semipublic,  and  personal 
hygiene,  55-97  {see  Hygiene);  results  of  con- 
serving, 102-116;  money  value  of  increased,  117- 
120;  cost  of  increased,  121-124;  general  valueof 
increased,  124-126;  principal  steps  to  be  taken 
toward.  126-129. 

Vital  statistics,  crying  need  of  better,  63-64, 126-127. 

Vivisection,  05. 

W. 

Wales,  vital  statistics  of,  16,  18,  20. 

Wallace,  Alfred  Russel,  cited,  30. 

Waring,  George  E.,  57. 

Warner,  books  by,  73. 

Washington,  D.  C,  lowering  of  death  rate  in,  24. 

Water  supply,  improvement  of,  lowers  death  rate 
from  typhoid  fever,  28;  importance  of  a  pure, 
29,  86,  107;  prevention  of  pollution  of,  58;  ex- 
pected results  of  Altering  of,  in  Pittsburg,  121; 
national  and  state  prevention  of  pollution  of, 
127;  measures  regarding,  to  be  taken  by 
municipalities,  128. 

Weber,  A.  F.,  cited,  24. 

Weishardt,  experiments  of,  41. 

Weismann,  mentioned,  50,  93. 

Wells,  danger  from,  59. 

Wells,  D.  Collin,  cited,  54n.'J 

Westergaard,  Harald,  cited,  25,  34,  112. 

Westinghouse,  example  of,  126. 

Weston,  E.  P.,  example  of,  44. 

Weston,  William,  quoted,  122. 

Wheeler,  Herbert  L.,  on  Children's  Aid  Dental 
Clmic,  New  York,  123. 

Whetham,  W.  C.  D.,  cited,  54. 

Wigglesworth,  E.,  life  tables  by,  18,  26. 

WUbur,  Cressy  L.,  on  need  of  better  vital  stctistics, 
63-04;  estimates  by,  114. 

Wiley,  on  food  preservatives,  95. 

Willcox,  W.  F.,  cited,  20,  119. 

Williams,  Henry  Smith,  cited,  88. 

Wing,  Frank  E.,  article  by,  121. 

Wisconsin,  accident  statistics  in,  37. 

Wives  of  diseased  men,  93,  94. 

Women,  regulation  of  labor  of,  59-60,  127;  clothing 
of,  86;  effects  of  gonorrhea  hi,  94;  rate  of  length- 
ening of  life  greater  among,  than  among  men, 
102. 

Wood,  Leonard,  quoted,  121-122. 


138 


INDEX, 


Wood,  Mary  L.,  centenarian,  112. 

Woodbury,  William  R.,  cited,  74. 

Woodman,  cited,  84. 

Woods,  F.  A.,  cited,  53. 

Woodward,  W.  C,  quoted,  58;  estimates  by,  114. 

Worcester,  Elwood,  71. 

Working  day,  lengtli  of  the,  45-46,  60-61,  92. 

Workingmen,  diseases  most  prevalent  among,  37-38; 
education  of,  in  subject  of  hygiene,  79-80;  over- 
work among,  92;  money  value  of,  118. 

Wright,  Carroll  D.,  cited,  118  n.d 

Wright,  F.  W.,  114. 

Wyman,  AValter,  quoted,  62, 122. 

X. 

X  rays,  use  of,  in  surgery,  65. 


Yale,  data  concerning  families  of  graduates  of,  54; 
observation  of  effects  of  tobacco  among  students 
at,  90. 

Yellow  fever,  lowering  in  death  rate  from,  in  United 
States,  Habana,  and  Panama,  30-31;  value  of 
discovery  of  transmission  of  germ  by  mosqui- 
toes, 121-122. 

Young,  T.  E.,  "Centenarians,"  by,  cited,  112. 

Young  Men's  Christian  Association,  work  of,  in 
interests  of  hygiene,  15,  47,  79. 

Z. 

Zeiss  factory,  eight-hour  day  at,  45. 


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1 

Annex 

